Common Billing & Coding Mistakes

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Source: Wakefield
May 26, 2024

Common errors in medical billing and coding can cost a practice time and money resulting in decreased cash flow, ultimately impacting your bottom line. You can avoid many mistakes by increasing your clean claim rate for positive processing outcomes.

Remember: the success of a claim begins as soon as your patient calls to schedule an appointment!

Patient Eligibility

A denial or rejected claim can start with the patient no longer being eligible for coverage or simply keying in the patient’s identification number incorrectly. Eligibility should be verified through payer portals and directly through practice management systems before every visit. Many practice management systems can allow for patients with scheduled appointments to check eligibility days prior to their appointment date. Reviewing eligibility before the patient’s arrival allows for timely contact and resolution.

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Verification of Benefits

Not only is ensuring the patient has active insurance coverage is imperative, also reviewing the types of benefits your patient is eligible for is key. Not all insurance policies are built the same which can potentially cause costly denials. For example, most policies allow for an annual wellness visit at no or little cost to the patient. However, “annual” can mean different timing per payer and/or policy. An annual visit may be covered once every 12 months or once per calendar year. Benefits can be viewed payer portals and practice management systems.

Inaccurate Coding

There are multiple code sets that are updates periodically throughout the year. Most commonly known are Current Procedural Coding (CPT), HCPCS, and ICD-10. Updates to CPT and HCPCS are published and made effective annually January 1st. To prepare your practice for the upcoming changes that may impact the services you bill, the new, revised, and deleted codes should be reviewed once the new publication is released.

ICD-10 updates become effective annually on October 1st. As more specific diagnosis are released, payers may deny unspecified diagnosis. Diagnosis should be coded to the highest specificity to avoid denials.

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Other common coding denials relate to bundling services. The National Correct Coding Initiative Procedure-to-Procedure Coding Edits is made available by CMS and is updated quarterly. When someone is coding multiple procedures on a claim, this resource identifies if the codes are billable together. So, if a modifier is required and the circumstances a modifier is allowed to unbundle the procedures.

In addition to the Procedure-to-Procedure Coding Edits, CMS also provides the Medically Unlikely Edits (MUE). Denials will occur when the maximum units is exceeded for a procedure code. The MUEs provides the number of times a procedure can be billed on a claim for a date of service the rational is also included for each CPT to indicate the reasoning for the max number of units.

Under Utilization of Practice Management System

During the coding and billing process, you can expect human error to some extent. These errors can include simply billing the incorrect payer or missing the authorization number on a claim for payers where it is known to be required. With each claim resubmission and corrected claim sent, the odd of reimbursement decreases. Utilizing your practice management system’s customizable claim edits tailored to your specific practice needs can catch a multitude of errors. The clean claim rate should continuously be monitored to make modification in your system.

Taking the appropriate steps utilizing resources can minimize common denials subsequently turning into faster and accurate claims payment beginning with initial patient contact to claim submission.