To prevent your practice from losing this revenue, avoid these five common coding mistakes.
Accurate coding is one of the most intricate and often frustrating tasks that doctors and staff must do. Erroneous coding can bring significant financial duress to a medical practice, either in the form of decreased revenue, audits, or even clawbacks from private insurers and revenue audit contractors (RACs).
Coding for evaluation/management services is often either too aggressive or too passive, and these coding errors are largely attributed to misinterpretation of E/M coding guidelines and the frantic pace of the clinical environment. Aggressive coding occurs when there isn’t proper documentation to prove out what was done. On the other hand, passive coding doesn’t take the entirety of the work performed into account.
Oftentimes, this is the result of incomplete charting, typically due to provider distraction. Charts without follow up typically result in the claim being sent late or unbilled.
The confusion between whether a patient is new or established, which should usually be established at the front desk, can lead to lower payments if the patient’s status is not properly captured.
Providers often miss administrative procedure codes for minor treatments, which can be a significant amount of lost revenue. This includes codes for injections, immunizations, immobilization, etc. Administering injections is among the most routine services provided in a primary care or urgent care practice, but one inoculation includes two codes: a CPT code for the injection, and a separate code for the medication or vaccination provided. Modifier 25 may also be applied if other care is being given. Another example of oversight can occur when placing a splint on a limb. There are two codes to enter: one for the application and another code for the supply item, such as a splint or a cast.
The largest errors are the improper use of modifiers 25 and 59 to expand treatment, which can lead to audits and clawbacks. Modifier 25 should be appended to an E/M code to report a significant but separately identifiable additional service rendered during the encounter, such as an injection. Modifier 59 is used to identify procedures/services other than E/M services that are not normally reported together but were appropriate to render under the circumstances.
These are only five areas of improper coding that lead to lost revenue; however, focusing on this list should make a significant, positive difference for the financial and operational well-being of your medical practice.
Roni Berlin, BSHCM, CPC, CPB, who serves as associate vice president at ExdionRCM Solutions, is a recognized expert in business strategy and analysis, medical coding, collections, and client support. The company’s solution, ExdionACE, is a powerful yet simple AI-powered coding, revenue integrity, and CDI (Clinical Documentation Improvement) solution.