Failing to provide accurate information and the right codes to support claims can lead to denials or delays as well as allegations of improper billing practices. Outsourcing medical coding tasks allows physicians to keep up to date with rules and avoid medical coding errors.
Here are common medical coding errors that practices need to watch out for:
- Assigning the wrong CPT code: There are thousands of CPT codes and these are updated annually. For instance, there were 314 CPT code changes in 2018, with 172 new codes, 60 revised codes and 82 code deletions. Moreover, changes vary by specialty. Coding accuracy can be ensured only by experienced, certified coders who are up to date with code changes and knowledgeable about medical terminology, anatomy, payer rules, and other essential elements.
- Unbundling codes: Unbundling refers to billing multiple CPT codes to obtain higher reimbursement for a set of procedures that can be captured by a single, comprehensive CPT code. Providers should take care to avoid submitting multiple bills for tests and services that were performed within a specified time period and which should have been submitted as a single bill. Blue Cross Blue Shield of California states: “Services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, are not eligible for separate reimbursement.” An example of an incidental procedure that is not separately reimbursable is the removal of an asymptomatic appendix when done during hysterectomy surgery.
- Upcoding: Like unbundling, upcoding is also considered fraudulent. Upcoding refers to submitting CPT codes for a more expensive service than was actually provided. Medical Economics recently reported on a ProPublica survey on payments made under Medicare’s Part B program in 2015 which found that more than 1,250 providers billed for every office visit using the 99215 code, which should actually be used only for visits that involve more intense examination and usually take more time.
- Not checking National Correct Coding Initiative (NCCI) edits when reporting multiple codes: In a recent report on coding mistakes, the American Medical Association (AMA) cautioned that physicians need to check the automated prepayment NCCI edits put forward by the Centers for Medicare & Medicaid Service (CMS) to ensure accurate coding. The NCCI edits, which were developed to prevent inappropriate payments for Medicare Part B claims, show when CPT codes should not be coded together during the same encounter. The AMA notes, “If there is an NCCI edit, one of the codes is denied.” For example, the APA Practice Organization points out that codes 90791 (psychological evaluation) and 96116 (neurobehavioral status exam) should not both be reported and paid for the same patient, on the same day, by the same provider. In this case, 90791 is reimbursable, while 96116 is not. Experienced coders in medical coding companies avoid billing edited codes together by consulting the NCCI when reporting multiple codes.
- Not linking the ICD-10 codes: CPT and HCPCS codes on the claim should correspond with the ICD-10 code that justifies the medical procedure. The claim would be incomplete if the procedure in the physician’s report as indicated by the CPT code is not linked with the listed diagnosis described by the appropriate ICD code.
- Not appending modifiers or inappropriate modifier use: Modifiers are appended to CPT/HCPCS codes to inform the payer of special circumstances. For instance, an E/M service can be billed on the same day as a surgical procedure when a patient’s condition requires a significant, separately identifiable E/M service beyond the usual care or when the decision to perform a major surgical procedure is made the same day as the surgery. In this situation, the appropriate modifier code should be appended on the E/M claim. Modifier 25 is used for significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service. The American Academy of Orthopaedic Surgeons explains that for joint injections, the preservice work includes explaining the procedure to the patient and/or family, discussing possible complications, and obtaining informed consent. The postservice work includes applying a dressing, monitoring for immediate side effects, providing recommendations on activity modification, and counseling the patient and/or family about symptoms and signs of possible complications. If the services provided in the E/M visit go beyond this typical pre- and postservice work, they can be considered significant and separately identifiable and reported by appending modifier 25. The documentation should explain why the additional work was necessary. Using modifiers requires a proper understanding of the global surgical package and NCCI edits.
- Improper injection code reporting: Only one code should be reported for the entire session involving injections. Improper reporting occurs when multiple units of a code are reported.
- Incorrect reporting of infusion and hydration codes which are time based: Infusion involves an IV medication administered for over 15 minutes or more, and hydration involves packaged fluids given through an IV for 31 minutes to one hour. For IV infusion hydration, 96360 should be reported for the initial 31 minutes to one hour (and not for hydration that lasts 30 minutes or less). Code 96361 should be reported for each additional hour, in addition to code for primary service. Code 96361 also indicates hydration using the same IV access as the initial hydration service. The AMA also points out that there are specific rules for reporting services provided over two days of service. For instance, if a continuous intravenous hydration is given from 11 p.m. to 2 a.m., the two administrations should be reported separately as initial (96374) and sequential (96376), instead of continuous infusion.
- Not including comprehensive documentation when reporting unlisted procedure codes: Unlisted procedure codes should be reported with proper documentation to describe the service. Payers will deny claims billed with unlisted procedure codes without narrative information and/or supporting documentation. Supporting documentation and details should include a clear description of the nature, extent, and need for the procedure or service, the patient’s diagnosis and risk of complications, etc.
Practices should establish coding compliance and documentation standards to ensure that all claims are submitted accurately. Outsourcing medical billing and coding to an experienced service provider is a viable strategy to ensure maximum reimbursement while avoiding audits and allegations of improper billing practices.