10 Medical Billing and Coding Mistakes to Be Wary of

By Karen Smiley

Medical coders are obligated to do everything within their power not to make errors, but everybody makes mistakes. Ethical violations are serious, and by virtue of your coder position, you have access to sensitive information related to patients’ health and financial well-being. Following is a high-level overview of some of the most serious infractions that may affect your bottom line.

Using unsupported documentation in medical coding and billing

Remember this mantra: “If it’s not documented, it wasn’t done.” Making physician queries can correct missing documentation, but remember to ask only neutral questions; never ask based on your assumption of what the code should be.

Medical coding from test results or symbols

Similarly, you shouldn’t code from test results that haven’t been documented by a clinician. The physician is responsible for stating the diagnosis based on testing. Nor do coders code from symbols such as up or down arrows.

Misusing modifiers in medical coding and billing

Modifiers indicate that the definition of a code has been modified. Informational modifiers, such as LT or RT, provide more specific information about the procedure, and payment modifiers, such as 59, affect reimbursement. Coding modifiers that don’t accurately portray the patient’s encounter is a huge no-no.

Mishandling overpayments in medical billing

Notifying payers when a claim has been overpaid is important. Sometimes this situation happens when a claim is inadvertently submitted twice — for example, when a corrected claim is sent but isn’t referenced as such. Many payers have a process or form that that they require for submitting a corrected claim, and the provider is responsible for submitting correctly.

Forgetting to bill the patient

When submitting a claim to a payer, you must also bill the patient for his portion. Say you bill an insurance company (or Medicare) for a service in the amount of $100. The payer allows the full amount and pays per plan benefit of 80 percent (or $80); the provider must bill the patient for the remaining $20.

Although patient debts are sometimes written off as uncollectable, every office should have a collection policy; usually, such a policy is to send a patient a minimum of three statements to demonstrate an effort to collect.

Billing under multiple medical provider numbers

Billing under multiple provider numbers for the same provider in an effort to capitalize on out-of-network benefits is against the rules. Some providers are listed in a patient’s provider directory as being in-network provider, which usually means those providers are lower-cost options.

Providers who deliberately accept these patients and then bill under a different number in order to receive higher, out-of-network rates from insurance are unethical at best, and in some cases possibly criminal.

Sharing or selling patient information

Sharing or selling patient information is a criminal offense. Identity theft is a growing problem, and medical providers have been identified as the new frontier. Patients supply personal details, including social security numbers, phone numbers, next of kin, and so on in good faith, and this information should be protected at all cost.

Ignoring an internal audit process

Not having a voluntary internal audit process can lead to trouble. As irritating as audits can be, they do serve a purpose. A well-run practice contracts with an outside auditor to perform random audits on the coding.

These audits are intended to educate the coding staff and ensure that the coders are current with regard to edits, use updated codes, and adhere to correct coding practices such as not over coding or under coding.

Disregarding aged claims

The 60-day mark is a good guideline to follow when monitoring accounts receivable. Any claim that remains unpaid after 60 days should be followed up and correctly noted. If the payer claims that the claim was never received, don’t just send another one.

You need to find out why the payer doesn’t have it. If the claim was sent electronically, check for an acceptance report. Sometimes one missing claim is an indication of a lost batch, and you definitely want to look into that situation — pronto.

Misrepresenting office policies to patients

Statements such as “we honor your in-network benefits” when you’re out of network is deceptive and may be construed as intent to commit fraud. An out-of-network provider can establish a policy that addresses financial arrangements available to patients, but it should not arbitrarily charge one patient $100 when the charge amount is normally billed at $200.