Thursday, January 25, 2024

Most Common Medical Coding Errors and How to Limit Them

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How To Avoid Medical Coding Errors?

You should agree that the success of the claims is in the hands of your medical coders. If medical coders are certified, experienced, up-to-date, and details oriented. Then you are in the right direction. If not, this is the right time to train them to avoid errors and improve coding performance.

Here’s a simple truth, though. Even professional coders sometimes make mistakes that can cause claim denial rates to increase and put revenue at risk.

Here are common mistakes medical coders may make and the steps you can take to prevent them.medical coding errors

Too Comfortable about their job

A skilled medical coder may get too comfortable with their work. But, on the other hand, perhaps a medical coder has seen these particular visits a hundred times and has the codes remembered.

They may feel that there is no purpose in wasting the extra time to study the codes because they know them already. But what happens if, or sooner, the medical codes are updated, replaced, or extended? Coders may not have all of the ICD-10 principles remembered yet, so they are likely not working without focus. However, they may get comfortable with a certain level of specificity versus actually taking the time to thoroughly read provider documentation and code to the highest level of specificity supported.

Missing Documentation

A typical coding rejection results when the coder selects the wrong code based on the new or placed patient guidelines. This type of error means checking all the details and reading the entire chart, not only the header.

In some cases, the provider won’t give the coder enough information about the procedure they’ve performed. For example, providers may leave important procedure details out of the report or provide illegible medical documents.  

A typical example is when a procedure is coded as ‘routine’ instead of correctly coded as ‘diagnostic.’ Most denials like this result from missing details in the medical record. These types of general denial claims can most likely easily minimize by simply double-checking work. In addition, if the quality is maintained and a coder’s performance is evaluated regularly, coders will pay more attention to the details they need to code correctly.

Taking Shortcuts

If you are trying to get somewhere fast, you force taking a shortcut. Sometimes a shortcut works excellent, but other times you get lost or arrive at a dead end. Backtracking your steps takes twice as long as it would have if you had just listened to Siri and taken her route from the outset. On the other hand, shortcuts may save some time in coding, especially when a coder feels overwhelmed by a large backlog of work.

But it is fixing the mistake after the fact is more costly and time-consuming than having done it right in the first place. Taking shortcuts is especially common when providers are selecting their charges. For example, a coder can think it is faster to enter the codes linked with the costs without evaluating the provider’s document.

Anyhow, a coder should carefully read the documentation and code only those procedures and services supported by the provider’s documentation. 

Poor Management Strategy

Any of the above mistakes can quickly compound and create damage to your coding accuracy. A strong coding leader regularly looks for process improvement opportunities in the coding workflow by evaluating what is working well and what isn’t. They also support continuing education sessions with the coding team. Analyze denial reasons, identify trends, build system edits, and review patient complaints all present opportunities for improvement.

Not Coding The Highest Level

The medical coder’s job is to code to the highest level of specificity. It means extracting the most data out of the medical reports from the provider and taking proper notes. It also means knowing the medical terminology for both procedures and diagnoses. Coding to a general level or under-coding can lead to a rejected or denied claim.

Not Having Access To The Provider

Ideally, every coder would be in regular contact with the provider they’re coding. But, unfortunately, that’s not always the case. Providers aren’t always available to consult on complex claims. Coders should do the best with what they have in these circumstances, but you should still try and simplify the report as best as you can.

Failing To Use Updated Code Sets

The WHO (for ICD), the AMA (for CPT), and the CMS (for HCPCS) organizations maintain the three principal medical coding code sets yearly. It’s up to coders to learn any new or reorganized regulations as they come out and use them correctly. Therefore, keeping your skills sharp is essential.

Under-Coding And Over-Coding

Under-coding is the committed reporting of less costly medical services performed, while over-coding reports more costly procedures performed. Both of these are dishonest and can lead to checkings and inquiries. Again, these aren’t errors, but we’re committed to mentioning them here as something you need to avoid.

Over-coding can happen when the billing staff makes a mistake when entering diagnosis and treatment codes or if the employee misunderstood the data provided by the doctor. Since codes for specific procedures and tests demand higher payments, this illegally increases your revenue as well. Over-coding will not only lead to claim denials but can also cause your practice to be punished.

Over-coding can be planned or accidental. It causes agreement issues because payers will have to repay providers at a higher rate. Therefore, it is best to provide valid codes to avoid claims rejection. 

Unbundling Codes 

Unbundling refers to using multiple CPT codes for the individual parts of the procedure, either due to misunderstanding or to increase payment.

Like under- and over-coding, unbundling is not so much of an error as it is a dishonest practice. Unbundling is closely related to over-coding in that it involves false reporting designed to earn the provider a higher payout from a payer. In addition, it is unbundling means separately coding procedures that would usually include in one umbrella code.

How to Avoid Medical Coding Errors?

Medical coding errors can prove to be highly damaging if they occur regularly. It can lead to losses of tens of thousands of dollars to hospitals, clinics, and physician groups. Some of the essential tips on preventing medical billing errors are listed here –

01. Use a Powerful System

Using billing systems capable of detecting common errors before submitting claims can help reduce the number of mistakes.

02. Have a Trained Team

It is important to hire highly skilled employees who are well-trained to handle any requests. In addition, the team must ensure that every submitted claim is new and not repeated to avoid duplicate billing.

03. Follow Joined Processes

The medical coding team must follow a unified process that aligns the group on the settled process to avoid unbundling and upcoding errors. 

04. Be Careful

Your work as a medical coder will be detail-oriented and full of little choices to make every day. However, you can avoid a lot of medical coding errors just by double-checking your work. Read over every medical report at least twice, and never be too familiar with a particular code set or set of procedure codes.

05. Communicate Usually

It’s not always possible to talk frequently with your provider. Still, you should improve connections at each provider’s office and try and communicate with them regularly. Communication will make it easier for you to ask them for an explanation on any detailed medical reports.

06. Stay Updated on  Medical Coding Manual

Generally, you have to update your coding manuals with their latest versions every year. In many cases, brand new manuals will provide by your employer as part of a work expense. But, if not, it’s worth it to buy new ones every year yourself. These manuals include new codes and revised guidelines, and having the latest edition is essential if you want to stay up-to-date.

The claim denials have increased for many practices Because of the medical code changes. The medical coders will be already busy with their working processes, and they won’t have more time to concentrate on the updated medical codes to ensure that they are using the most accurate codes.

The medical coders should spend some time making the right effort to stay updated on the latest medical codes and any coding changes.

07. Ensure That Coders Are Aware of Bilateral Services

Bilateral services and procedures such as X-rays, vaccinations, and medications need to highlight explicitly so that the coders become aware that it includes the medical care service. When coders and providers work at a different location, the biller will not know the bilateral services if the physician forgets to mention them.

Coding Must Be Highly Specific

A coder’s responsibility is to take care of and ensure that every code is unique. Some ICD-10 regulations need the last two digits to be highly accurate to avoid rejection of medical care claims. Whenever coders face the difficulty of whether the diagnosis is accurately coded or not, it is safe to refer to the codebook.

The key is for coders to thoroughly review all provider documentation before selecting the appropriate codes to avoid common medical coding errors. There is no replacement for this. Additionally, coding leaders should continuously study processes and workflow strategies to ensure the running of high-quality coding staff.


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I am a medical biller, a blogger and have 20 years of experience in medical billing, medical billing management, and medical assistant. My background includes positions as a clinical medical assistant, medical records technician, medical office manager, biller, and coder. I am certified by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) and by the Practice Management Institute (PMI) as a Certified Medical Office Manager (CMOM). As an office manager/biller/coder, I was a member of the Michigan Medical Group Managers, Michigan Medical Billers Association. I also served as a committee member of the Michigan Osteopathic Association of Practice Managers Education Committee.

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