Government and private payers conduct audits to find out fraudulent or abusive medical billing practices. As a provider, you deserve to be paid accurately for the medical care you provide. At the same time, it’s essential that you avoid improper billing practices to steer clear of trouble and maintain a flourishing practice. In this article, we discussed common medical coding errors that could cost you a lot if such an audit happens. If you avoid these mistakes you will be avoiding coding audits from these payers.
Avoiding Coding Audits
When it comes to medical coding errors, they are categorized as ‘fraud’ and ‘abuse.’ ‘Fraud’ involves intentional misrepresentation while ‘abuse’ represents innocent mistakes resulting in falsification. An example of ‘abuse’ could involve coding for a more complex service than was performed due to a misunderstanding of the coding system. Some of the coding mistakes that can attract coding audits are as follows:
Unbundling
Unbundling refers to using multiple CPT codes for the individual parts of the procedure, either due to misunderstanding or in an effort to increase payment. When there is a single code available that captures payment for the component parts of a procedure, that is what should be used. Reporting to the highest codes rather than actual code is called upcoding. When you code for evaluation-and-management (E/M) for complex patients for oncology specialty, you tend to report the highest-level evaluation-and-management (E/M) service regardless of the actual condition your patient presents with. You must accurately report the level of E/M code based on the patient’s condition and not just based on specialty. Examples of fraud could be, billing 30- or 60-minute face-to-face sessions with patients as a psychiatrist while in reality seeing patients only for 15 minutes each to do medication checks.
National Correct Coding Initiative (NCCI) Edits
You need to check National Correct Coding Initiative (NCCI) edits when you are reporting multiple codes. The Centers for Medicare & Medicaid Services (CMS) developed the NCCI to help ensure correct coding methods were followed and avoid inappropriate payments for Medicare Part B claims. These are automated prepayment edits that are ‘reached by analyzing every pair of codes billed for the same patient on the same service date by the same provider to see if an edit exists in the NCCI’. If there is an NCCI edit, one of the codes is denied. NCCI edits will typically provide a list of CPT modifiers available that may be used to override the denial. In certain cases, clear direction is stated that no modifier may be used to override the denial. Just consider an example, as per NCCI edits simple repairs are included in the excision codes, so separately coding the repair would be wrong. But if the repair was performed on a different site from where the lesion was removed, it is appropriate to bill for both and append a modifier to let the payer know the procedure was indeed separate from the excision.
Incorrect Use of Modifiers
Using the wrong modifier or using the same modifier again and again could attract an audit. For lesion excision examples mentioned above, using modifier 50 (bilateral procedure) along with correct CPT is the correct coding practice. Most coders use modifier 22 (increased procedural services) repetitively. When you are using modifier 22, you must support it with proper documentation to explain why the procedure requires more work than usual. Consider an example, provider excise a lesion located in the crease of the neck of a very obese patient. Obesity makes the excision more difficult. In such a case, appending the modifier 22 to the code used to report the removal can indicate the increased complexity of the service.
Improper Reporting Time-based Codes
Good documentation of the start and stop times is essential for medical coders to properly bill for time-based services. And then there are wrinkles involving services that are provided over two days of service. Continuous intravenous hydration is given from 11 p.m. to 2 a.m. In that case, instead of continuous infusion, the two administrations should be reported separately as initial (96374) and sequential (96376).
Most small practice owners tend to do coding and billing all by themselves but this could attract billing and coding audit. As every payer has their unique coding guidelines and reimbursement policies, just for sake of getting insurance reimbursement using wrong procedure codes along with modifiers could be troublesome. If you are trying to save some amount for doing it all by yourself then wrong coding could cost your practice more. You can take assistance from outsourcing medical billing companies like MedicalBillersandCoders (MBC) you will charge you only based upon insurance reimbursement received. You don’t have to worry about procedure codes, modifiers, changing reimbursement policies, and coding guidelines. We will code accurately, submit clean claims, post the received payment, and can take off old pending claims. To know more about our billing and coding services, contact us at info@medicalbillersandcoders.com / 888-357-3226.
FAQs
1. What are common medical coding errors that can trigger audits?
Common errors include unbundling procedures, using incorrect modifiers, improper reporting of time-based codes, and ignoring National Correct Coding Initiative (NCCI) edits.
2. What is unbundling in medical coding?
Unbundling occurs when multiple CPT codes are used to report individual components of a procedure instead of a single, comprehensive code. This can lead to overpayment and attract audits.
3. How can I ensure the correct use of modifiers?
Modifiers should be used appropriately to reflect the complexity or context of the service. Proper documentation is crucial to justify their use, especially for modifiers like 22 (increased procedural services).
4. What are NCCI edits, and why are they important?
NCCI edits are automated prepayment rules established by CMS to prevent improper coding combinations. Following these edits helps avoid claim denials and ensures compliance with Medicare guidelines.
5. How can outsourcing billing and coding help avoid audits?
Outsourcing to experts like MBC ensures accurate coding, adherence to payer-specific guidelines, and clean claims submission, minimizing errors and the risk of audits. For assistance, contact us at info@medicalbillersandcoders.com or 888-357-3226.
