Medical billing reimbursements largely depend on the accuracy of medical coding. During the processing of claims, a substantial amount of time is devoted in tallying codes. If the coding matches the diagnosis or procedure, claims get cleared easily. If there are errors, then it leads to delays. And if the errors are glaring, then it leads to denials. In this blog we look into the primary coding errors that can cost you a clean reimbursement.
Documentation Errors
Documentation errors happen because of multiple reasons. These include prescribing errors, transcription errors, administrative documentation errors etc.
Much of these errors can be kept in check by having a proper mechanism in place. Foremost among them are providing up-to-date training to clinicians and in-house administrative staff.
The training must include knowledge of changing medical legislation, medications, unknown allergies, contraindications, having a proper cross-checking mechanism in place including protocols for prescription orders, abbreviations, drug-lists, enquiring with pharmacists etc.
An easy way to check on errors is to bank on software and other technologies. These systems can flag errors and missing fields on their own and help you bring down errors to almost zero.
Reasons for Documentation Errors· Incorrect interpretation of prescription drug orders · Dictation errors while keying in notes · Selecting the wrong medicine after entering first few letters · Accidental entry of wrong medication dose like daily for weekly · Difficult the read handwriting · Incorrect use of abbreviations |
Unbundling
Unbundling” is a medical billing fraud. Sometimes, it is committed inadvertently, but is interpreted as a deliberate attempt to mislead. It involves billing multiple procedures separately, in place of one available code. As a break-up in billing helps the practice recover more money for the same procedure, it is considered as fraud.
Here’s a good example for unbundling – entering separate codes for incision and suturing for a regular surgical procedure, instead of the standard billing code. This helps the practice in extracting more money from the payer.
The practice of unbundling can invite heavy penalties. As it is sometimes committed inadvertently, practices can ensure this doesn’t happen by training employees adequately and having a fool-proof quality check mechanism in place. Every bill generated must go through a thorough quality check by experienced billers to spot issues like unbundling.
Upcoding
Upcoding is another type of fraudulent medical billing. In this type of billing, practices tend to make more expensive claims than it should actually be. This primarily happens by assigning codes that are more expensive than what was performed. Few examples of these include, billing for a complex X-ray when a simple one was performed, or billing sedation as a complex anesthesia, or billing for a procedure performed by a nurse as one performed by the doctor.
Upcoding is a fraud and is interpreted as an attempt to cheat the system. As a practice, healthcare providers must refrain from doing this. Employees need to be made aware of the consequences of this malpractice. As this kind of malpractice is sometimes committed without the knowledge of doctors or administration, it is important to take every through a quality check to identify upcoding.
Undercoding
Undercoding is the opposite of upcoding. It is also known as downcoding. In this type of coding, certain documentation details are deliberately omitted. In the process the procedure is not provided with the desired degree of specificity. Some practices do this deliberately to eliminate chances of claims denial. Sometimes, this also helps in keeping matters away from audits. As per regulatory requirements, undercoding is a violation of the principles of medical coding. It is also viewed as an attempt to tamper with the system. In fact, one of the reasons for moving over to ICD-10, was to improve the process of ensuring accuracy in matching diagnosis.
One disease that commonly goes undercoded is Diabetes. This happens when physicians or practices simply code this disease as “diabetes without complications.’ As per rules, it is mandatory to report the specific type of diabetes for which treatment has been administered and the steps taken to control must be fully documented.
Like upcoding, undercoding can also be checked by awareness and hiring the right professionals. Besides, providers need to leverage advanced tools to ensure undercoding gets flagged. It also helps to have an internal audit team to audit for upcoding and undercoding.
Duplicate Billing
Duplicate billing means trying to get paid twice over by issuing the same bill to two different payment parties. It can be like billing either Medicare/ Medicaid along with a private insurance company or the patient for the same procedure. This can also happen when two different providers send the same bill for procedure performed to the same patient and on the same date. Likewise, any attempt to charge more than once for one particular service is interpreted as duplicate billing. For instance, billing as an individual code and also as a bundled set of tests is viewed as duplicate billing.
Duplicate billing is viewed as a fraudulent attempt to get paid more than what is due. It may invite fines and affect provider reputation. The best way to avoid this is by being extra cautious and taking the billing procedure through multiple stages of quality checks.
Conclusion
Mistakes in medical billing and coding process can prove to be very costly for providers in either the short or long run. Therefore, healthcare practices need to take all possible measures to ensure cent percent accuracy in medical coding. One easy way is to outsource the task to medical coding outsourcing companies in USA or a third-party medical coding company.
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