Discover why better documentation is the best defense against these mistakes.
There’s good news and bad news about improper Medicare Fee-For-Service payments.
The good news is the improper payment rate fell from 11% in 2016 to 9.5% in 2017—a $4.9 billion decrease.
The bad news? According to CMS, most improper payments were “due to documentation errors where CMS could not determine whether the billed items or services were actually provided, were billed at the appropriate level, and/or were medically necessary.”
A quick review of common medical coding errors spotlights the crucial need for physicians to provide thorough and accurate documentation. That’s one reason we developed MDCodePro; to give today’s busy, hard-working practitioners the knowledge they need to document what they do the right way, the way that complies with regulatory guidelines and supports the maximum reimbursement they have earned.
So what are some of the most common medical coding errors—and how can better documentation prevent them? Let’s look at five.
5 Most Common Medical Billing Mistakes
#1: Non-specific Diagnosis Codes
CPT® codes identify what services you provide. Diagnosis codes identify why. They establish medical necessity, which determines what services payers cover. But too often, submitted claims lack adequately specific diagnosis codes, leading to denials, revenue shortfalls, and audits.
“The change from ICD-9 to ICD-10 has drastically increased the level of detail that can be reported using a diagnosis code,” writes Jessica Short, certified professional coder and medical auditor. “It is more important than ever to be as clear and specific as possible in the documentation and when selecting the diagnosis code.”
ICD-10 codes can indicate the severity and complexity of a patient’s condition, along with comorbidities and complications. But choosing the right code starts with physicians documenting patient visits in the right amount of detail.
If it costs your auto mechanic $600 in parts and labor to replace a timing belt, he or she won’t bill you for $300. Yet too many physicians charge less than their specialized knowledge and work are worth. In 2016, according to CMS’ Comprehensive Error Rate Testing (CERT), undercoded claims across all services cost providers more than $1.2 million.
Undercoding is another common consequence of insufficient documentation. If a physician’s note doesn’t contain enough detail about a procedure, a coder may fall back on a general code, resulting in lost revenue.
Some undercoding happens because practices mistakenly think it protects them from audit. But this unsound strategy not only shortchanges the practice but also leaves it vulnerable to charges of fraud. As the AAPC recommends, conduct regular internal audits and periodic external ones to combat undercoding.
#3: Mistaken Modifiers
CPT® code modifiers are two-letter or two-digit suffixes intended to communicate extra information about a procedure succinctly and clearly. Unfortunately, modifiers cause physicians and coders a lot of confusion. For instance, according to the AAPC, “Modifiers 25 and 59 are misapplied so often, claims with these modifiers are automatically flagged for review and additional documentation is often requested.”
Even a brief look at those two modifiers show there’s plenty of room for misunderstanding. While both designate separate services provided on the same day, modifier 25 records E/M services, but modifier 59 doesn’t, and is appropriate only when no other choice is available.
Because modifiers can directly affect how much you get paid, you literally cannot afford to ignore them. To avoid mistakes, make sure you’re referencing up-to-date resources, stay familiar with the insurance companies’ modifier policies, and provide documentation detailed enough to justify the chosen modifier. And never abuse modifiers by using them to “unbundle” or “fragment” procedures and services that belong together—it’s unethical and illegal.
#4: Copy-Paste Problems
An electronic health record (EHR) system makes it easy for time-pressed physicians to copy-paste (or “copy-forward” or “clone”) documentation. But If they don’t do so carefully enough, problems result.
Out-of-date or redundant information may obscure a patient’s current condition. Procedures performed only once may be recorded and submitted for reimbursement multiple times—or codes for procedures never performed might make their way to a payer.
“I see the contradictions in the records a lot,” auditor Patricia Trites told AHIMA. “From an auditor’s standpoint, you don’t know which [documentation] is true and which is accurate, how much work was actually done on this visit versus last visit.”
To reduce the chances you’ll make a copy-paste mistake, minimize your use of the EHR cloning functionality. Restrict it to copying a patient’s demographics, regular medications, and long-standing, ongoing conditions (such as allergies.) Document the rest of each visit from scratch to ensure an accurate, detailed record of what you observed and what services you performed.
#5: Missing Information
Fortunately, one of the most common medical coding errors is also one of the simplest to fix: missing information.
Date-specific information—date of accident, date of medical emergency, date of onset—tends to go missing most often. But sometimes other pieces of the claim puzzle are absent, including the referring physician’s NPI or the valid form of the patient’s name (for Medicare claims in particular, it must appear exactly as it does on her or his Social Security card.)
Incomplete information leads to rejected claims, which leads to less revenue. When completing a patient’s medical record, double-check that you’ve filled in all the blanks accurately and legibly. Taking the time to do so will save you time in the long run, because claims won’t be returned to you due to insufficient information.
Want to Know How to Reduce Medical Coding Errors?
We can’t stress it enough; when physicians develop the habit of providing more detailed and more accurate documentation, these and other common medical coding errors become less likely.
MDCodePro stresses documentation in its physician coding training. Our video lecture series will guide you through the essentials of the CMS regulatory guidelines, giving you a high-level perspective and easy ways to remember how to document patient visits to support the highest appropriate level of complexity/risk. And our Code Generator uses your documentation to give you the optimal code for each visit, ensuring you receive the most revenue to which you are entitled for the services you’ve provided.