The success of medical billing rests on timely reimbursements, which is a breed of accurate claim submission. The claim submission relies heavily on initial documentation, but the coding performed to generate a claim marks a crucial juncture in the medical billing process. Medical coding errors have become prevalent recently due to the added complexities to the already intricate process. To stay up-to-date with the fluctuating demands of the healthcare sector, medical coding has to be reviewed after some time. This adds to the challenge of staying accurate and compliant in medical coding while ensuring that only a little time or resources are consumed. This article will review why it's mandatory to avoid medical coding faults, ten most common medical billing mistakes and how to prevent them.
Medical coding malpractice can dent the quality of care that a provider must render to the patient. In the wake of upcoding, the provider can be subjected to severe legal consequences if found guilty of intentionally doing it. Even if unintentional, it can significantly erode the patient and insurers' trust in the provider. An error-prone medical coding system labels a provider as unprofessional and unethical. The financial system rests on timely reimbursements. Medical coding negligence can cause denied claims, leading to a long queue of delayed reimbursements that will impede the provider from rendering care. Apart from all that, medical coding is a complicated process that demands adherence to specific protocols and guidelines. As a result of a medical coding lapse, you might breach them, resulting in extreme events such as license cancellation.
In this section we will discuss some of the most common medical coding errors. We will discuss how a minor error can lead to major damages.
Unbundling is a malpractice in which practitioners submit more than one code for a single procedure composed of more than one component. In such scenarios, the procedure should be billed as a single package in accordance to the established guidelines. If done otherwise, it will result in an unfair increase in reimbursement amounts that could cost patients and insurers dearly. For instance, in lab testing, there might be an instance of such a comprehensive blood test; in such cases, a single pre-existing code should be used to record the test rather than billing each test separately. The process is against the law and can lead to hefty losses for patients and providers.
The coding accuracy of a facility is significantly dented due to both overcoding and undercoding. Overcoding represents an overcharged claim in which the provider bills for a more advanced service than rendered, unjustly increasing the reimbursement rate. The negligence of the coders can cause it. However, well-organized fraud in this regard is also a possibility. Contrary to this, undercoding, as the name suggests, represents billing less than the magnitude of the service. It can badly impact the revenue cycle of a healthcare facility as reimbursement is way less than a due one. As the nature of both services is opposite, the outcome is quite similar as both can lead to financial losses and badly impact the image of a provider. A provider needs to follow ethical guidelines to portray compliance. Overcoding and undercoating are serious threats that hinder this process.
Accuracy is essential in medical coding, as even the slightest errors can result in heavy financial losses. The progressive landscape of medical codes, which spans over 78,000 ICD-10 codes alone, tests the mettle of medical coders. The icing on the cake is the addition of new codes by the Centers for Medicare & Medicaid Services (CMS) every now and then to meet the needs of a demanding healthcare sector. This necessitates coders to stay up to date to ensure accurate coding, which is among the first ranks for medical billing mistakes. In such a scenario, a hectic work schedule and long working hours can drain coders already performing a tough job. This increases the possibility of errors occurring.
CMS introduced a National Correct Coding Initiative (NCCI) to promote accurate Medicare Part B Claims coding. These edits ( NCCI) prevent duplicate payments by identifying the code combination, hindering it from getting billed together, and ensuring correct code usage. However, negligent coders need to pay more attention to the importance of these edits. Not paying heed to NCCI edits leads to the billing of multiple codes for one procedure, which leads to claim denials impacting both the patient and provider. It has become one of the most common medical coding woes. It is highly advisable to give NCCI due attention, especially when the patient is in a critical situation and multiple procedures are done on the same day. Hefty financial losses can be avoided with this simple method.
When a medical service is rendered to a patient, and they are billed more than once for the same service rendered during the same visit, it is called duplicate billing. Such medical coding errors can lead to overcharged bills and jeopardize patients. It results from malpractice on the part of coders or any glitches in the medical coding system. It can dent the reputation of a healthcare facility. To avoid it, claims should be validated before submission, and a thorough audit should be conducted if the issue is recurrent to identify where the real problem lies.
One of the most prevalent concerns in medical coding is the inappropriate usage of modifiers. Modifiers are used in addition to the conventional codes to explain or elaborate any extra information. If we were to go by the reports of the American Medical Association(AMA), Modifier 22, which depicts the complexity of a procedure, should be used more. Insurers have also complained about the medical coding errors associated with adequately applying modifiers 25,50 and 59. The leading causative agent needs to be adequate documentation. Consider a hypothetical situation of an obese patient being subjected to the removal of lesions. In such scenarios, the application of modifier 22 is paramount as it depicts the complexity involved. However, if the procedure is inadequately documented, it increases the chances of errors.
Services rendered from the start until the end should be cohesively documented to ensure pinpoint, accurate billing and timely reimbursements. However, the process gets comparatively complicated when the services are rendered on two consecutive days, requiring a well-rounded approach to medical coding. For instance, if IV is administered from 10 p.m. to 2 a.m., the coding strategy necessitates using different codes for initial and sequential administrations. This is because reporting multiple relevant units of the same code is paramount in minimizing the risk of medical coding errors. However, to make all this possible, proper documentation is required.
Phantom Billing is a malpractice in which providers submit claims for services never provided to the patient. This unacceptable practice is a result of negligence on the part of coders. It can also result from on-purpose unethical practices that can significantly erode the patient results and result in serious legal consequences for the provider. To combat this pressing issue effectively, providers must improve the overall billing and record-keeping processes and establish clear communication channels with outsourcing billing entities.
Mismatched patient information is a medical coding mistake in which the patient data submitted by a provider in a medical claim does not resonate with the records. Leading causes for such issues are typing errors, obsolete information, and compromised verification processes. This negligence by the medical billing team can lead to claim denials and delayed reimbursements. Data should be updated regularly to mitigate this, and streamlined verification protocols should be in place.
Code linkage is often underestimated as a contributing factor to accurate medical coding. It justifies the claim, ensuring a timely reimbursement. To understand the overwhelming significance of it, consider this example. A patient visits a doctor and complains about lower back pain. The provider diagnoses the condition for which the medical billing entity assigns a specific code. Next, a procedure is done to alleviate the symptoms, also given the relevant code. Correct code linkage in such scenarios involves the diagnosis code) with the adjacent procedure code. However any error in accomplishing the task will result in a straightaway claim denial. This linkage is used to justify the claim and explain the medical necessity of the procedure performed.
In order to prevent medical coding mistakes, providers, their staff and coding professionals should abide by established guidelines. Staff members should be well-versed in coding guidelines and actively participate in ongoing training sessions. Accurate documentation must be the order of the day. Audits should be conducted to detect the reasons, sequence, and prevention of errors happening again in the future. Compliance must be observed at all times. Adherence to National Correct Coding Initiative edits must be emphasized upon. Any unethical coding activity must be dealt with rightfully to avoid such activities in the future. Coders should be foretold about modifiers' importance and how to use them appropriately.
Meds Nexus has years of experience helping healthcare facilities thrive by streamlining their medical coding procedures. We have expert coders proficient in navigating the complicated world of healthcare coding. They attend ongoing training sessions to keep themselves relevant and compliant. We offer well-rounded audits that give you a glimpse into your practice, and you learn about the areas you lack. Meds Nexus is your go-to destination if you want to eradicate medical coding errors.
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