Even minor errors can have major consequences in delayed or reduced payments, denied claims, and compliance risks.
We cover the most common coding and billing mistakes along with best practices to identify where vulnerabilities exist and prevent pervasive issues.
High Cost Medical Coding Errors to Avoid
Medical coding translates clinical details from patient visits into the standard code sets used for billing, data analysis, and public health reporting.
Coding inaccuracies significantly impact revenue and compliance:
Missing Codes
Failing to code for all diagnoses, procedures, supplies, and ancillary services provided results in leaving legitimate reimbursement on the table. Thorough coding is essential.
Incorrect Code Assignments
Choosing the wrong codes for clinical events leads to improper reimbursement rates. Code selection should precisely match documentation.
Inadequate Specificity
Coding diagnoses and procedures broadly or generically rather than most specifically as documented shortchanges revenue especially under severity-tiered systems like DRGs. Capture all nuances.
Unbundling
Breaking out component codes individually that should be billed together under one code creates billing redundancies that payers may reject or audit. Follow coding guidelines carefully.
Upcoding
Assigning codes reflecting higher complexity or severity than clinically documented to obtain higher reimbursement is unethical and illegal. Code to the level of clinical details.
Duplication
Duplicate coding for the same procedure, supply, diagnosis etc due to typos or system errors prompts payers to flag as duplicate or suspicious claims.
Invalid Linkages
Connecting diagnosis codes improperly to reported procedures can lead to denied claims and compliance issues. Code linkages must align accurately.
Insufficient Modifiers
Omitting necessary coding modifiers to convey additional details like anatomical site, underlying conditions, and quality leads to misrepresentation.
Bad Sequencing
Diagnosis codes presented out of order or hierarchy based on coding guidelines hinders reimbursement and distorts clinical picture.
Grouping Errors
Placing codes in the wrong groupings on claims obscures clinical story leading to denials or misrepresentation of health status. Structure codes logically.
Staying current, clinically accurate, and highly specific with comprehensive documentation review is key for ethical, compliant coding.
Common Medical Billing Errors Undermining Revenue
Beyond coding, physician billing processes are prone to issues negatively impacting payment and revenue:
Inaccurate Patient Information
Wrong patient details like names, DOB, policy numbers lead to immediate claim rejection. Verify all demographics match.
Diagnosis and Procedure Discrepancies
Billing diagnosis and procedure codes that mismatch the treating provider’s documented clinical details prompts denials. Keep coding consistent with records.
Timed Coding Errors
Inaccurate coding of treatment duration, medication administration times, or anesthesiology minutes distorts case complexity resulting in incorrect payment.
Authorization Failures
Lack of required pre-approvals, pre-certifications or referrals provided results in widespread denial of services not authorized. Obtain all mandate approvals.
Invalid Place of Service
Billing for inappropriate or inaccurate care setting prompts delays or denials. Always specify the place of treatment truthfully.
Missing Modifiers
Omitting billing modifiers like -24, -25, -59 representing critical treatment details frequently causes misrepresentation and underpayment.
Incorrect Units
Under or overstating units of drugs, supplies, tests on billing forms raises flags for audits of billing accuracy and necessity.
Billing Duplicates
Inadvertently submitting claims more than once due to errors like system clones prompts delays or rejections as suspicious duplicate claims.
Timeliness Issues
Missed payer claim filing deadlines due to lagged submission quickly leads to upfront rejections. Take note of time limit requirements.
Poor Handwriting
Illegible handwritten claim details requiring additional documentation or interpretation stall payments. Use printed forms or tidy writing.
Meticulous claim preparation and rigorous review prevents many revenue disruptions.
Top Claim Denial Triggers to Overcome
Beyond billing process flaws, certain denial triggers arise:
No Pre-Authorization Obtained
Lack of required pre-approval for procedures results in widespread denial. Secure written pre-authorization and include proof with initial claim.
Insufficient Medical Necessity Documentation
Payers deny claims lacking adequate documentation justifying the medical necessity for treatments provided. Include full clinical narratives.
EOB Errors
Sometimes EOB denial codes cite incorrect reasons unrelated to the claim’s actual deficiencies. Thoroughly review and identify incongruous explanations.
No Referring Provider Details
Missing ordering provider info like NPIs on claims hampers processing and triggers denials. Populate referring practitioner IDs.
Invalid or Expired Policy Numbers
Outdated insurance policy ID numbers cause immediate rejection. Check numbers match current health plan records exactly.
Incorrect Form Versions
Using outdated claim form versions prompts rejections. Verify form usage adheres to current payer specification manuals.
Coordination of Benefits Errors
Incomplete coordination between primary and secondary insurances leads to complications or delays in one or both paying. Coordinate carefully.
Patient Responsibility Miscalculation
Applying incorrect deductibles, copays or coinsurance amounts based on policy terms leads payers to reject claims due to misaligned patient responsibility.
Spot checking for leading triggers exposes vulnerabilities for improvement.
Billing Department Areas Prone to Revenue Disrupting Errors
Certain billing functions see higher error frequency:
Front Desk
Registers patients inaccurately, collects incorrect upfront payments, fails insurance eligibility checks, misses authorizations.
Coding
Codes diagnoses and procedures incorrectly, sequencing errors, DRG misassignments, outdated code usage.
Claim Compilation
Claims submitted with missing details, incorrect formats, stale patient data, invalid policy numbers.
Submission
Sending claims to wrong payers, passing submission deadlines, submitting duplicate claims.
Payment Posting
Posts payments to wrong accounts, underpays claims by failing to identify full owed amounts.
Analytics and Auditing
Lack of detailed data visibility into errors, trends, high risk claim types. No audits to ensure billing correctness.
Targeting the departments contributing the most errors has significant impact on lowering denial rates and preventing revenue erosion.
Upfront Insurance Eligibility Verification
Confirming active accurate patient coverage is crucial:
- Verify insurance eligibility electronically or via phone on day of appointment.
- Get written authorization numbers for validation.
- Confirm patient details like name, DOB match card presented.
- Note effective dates, policy changes, out of network restrictions.
- Accurately collect any copays or coinsurance percentages.
Faulty eligibility status leads to immediate claim rejection once submitted. Verifying patient identity and insurance coverage matches mitigates common claim errors.
Staff Training for Proper Coding and Documentation
Equipping staff with latest payer policies and precise coding practices improves billing accuracy:
Annual Compliance Training
- Review coding guidelines like medical necessity, bundling rules, modifiers.
- Share new regulations on documentation, eligibility checks, authorizations.
- Discuss evolving payer policies tied to coding, pre-approvals, Place of Service.
Specialty Coding Nuances
- Provide regular continuing education on coding specific to specialties like cardiology, orthopedics, OBGYN etc.
- Include training on top denial reasons and overturn success tactics.
Coder Certification
- Require coding staff obtain Certified Professional Coder (CPC) credential demonstrating competency.
- Encourage earning specialty credentials like Cardiology Coder (CCC) as relevant.
Clinical Documentation Guidance
- Educate clinicians on optimizing visit note narratives to support accurate coding and necessity justification.
- Provide templates highlighting details needed.
Consistent payer policy and coding education improves staff skills.
Performing Regular Coding Audits
Routine coding audits by experts improve accuracy:
- Audit a sample of patient charts coded each month to check for errors like incorrect code assignments and validity of linkages.
- Target complex cases like surgeries as well as high E/M services levels prone to errors.
- Provide coders detailed feedback on mistakes found and training opportunities.
- Track audit error rate percentages over time as a performance metric.
- Leverage audits to identify documentation improvement opportunities as well.
Proactive self-auditing provides objective visibility into coding accuracy and vulnerabilities.
Improving Coordination Between Clinical and Billing
Tight collaboration between clinical and billing/coding staff helps resolve errors:
- Include billing representatives in regular clinical department meetings to share emerging challenges and coordinate on resolutions.
- Review resolved claim denial cases collectively to identify how documentation or coding contributed and can be improved.
- Implement a formal inquiry process for billing to request added details from clinicians when records lack sufficient documentation.
- Develop EHR documentation tools like templates and prompts that capture details needed to code fully.
- Facilitate round table discussions between coders, clinicians and billers to align understanding of documentation and billing requirements.
Bridging clinical and billing silos through communication and collaboration prevents errors.
Leveraging Claims Editing and Auditing Software
Automated systems add significant value:
Claims Auditing Software
- Claims scrubbing apps use rules to catch errors like invalid codes and misapplied modifiers before submission.
- Analytics identify high frequency mistakes by provider, coder, claim type.
Automated EOB Auditing
- Tools like Platelet’s EOB Guardian analyze EOBs/remits against billed claims to catch underpayments.
Robotic Process Automation
- Software bots extract unstructured data needed for coding/billing from clinical notes and paperwork.
Text Search Tools
- Solutions like Clinithink leverage AI to scan clinical notes to ensure documentation supports codes billed.
Automated systems boost coder productivity while reducing costly errors.
Implementing Medical Code Auditing and Validation Solutions
Specialty audit software improves coder accuracy:
Code Auditing Applications
- Coding audit systems like CodeRyte flag improper E/M leveling, misused codes, unbundling, upcoding etc. based on documented details.
Encoding Software
- Encoders like CodeFinder crosscheck recommended codes against payers’ local and national coverage determinations.
Anatomy Illustration Tools
- Software like Visible Health visualizes anatomy diagrams and descriptors to select appropriate codes descriptively.
- CodeCalculator analyzes note times documented related to counseling, coordination of care, medication management and other factors to validate appropriate E/M level selections.
Specialized validation solutions provide an added safety net identifying coding errors for correction pre-claim.
Seeking Regular Coding and Documentation Updates
Billing codes and rules constantly evolve:
- Review newsletter updates from payers and AMA on changing diagnosis/procedure codes, rules, and documentation requirements.
- Bookmark coding resource websites and payers’ provider portals for reference access to evolving guidelines.
- Consult with experienced certified coders and billers through peer organizations or support services to clarify complex changes.
- Take continuing education courses related to coding updates, common denial analysis, and billing best practices.
- Attend conferences delivering sessions on coding optimization, new regulations, and payer policies.
Proactive education helps coding remain current as guidelines continuously modernize.
Summary
Accurate coding and meticulous claim preparation provides the foundation for solid revenue cycle performance. While some claim errors and denials remain inevitable, strategic focus on improving documentation, elevating coder skills, coordinating across departments, leveraging technology, and instilling a culture of quality eliminates many preventable mistakes undermining reimbursement and compliance. Applying these best practices paves the way for cleaner claims, faster payments, reduced denial write-offs and greater financial stability.
