Medical billing and coding is the foundation of the revenue cycle in healthcare. Their job is to encode all the patient-physician visits into universally recognized codes used by healthcare providers, government agencies, and insurance payers. Because the medical coding process has many subtleties, and selecting the right codes has a direct impact on compliance and revenue, looking for potential red flags is vitally important. No matter what your level of medical coding experience, these are red flags for which every biller and coder should be actively aware.
Incorrect Coding Modifiers
Medical coding is a science and choosing the right modifiers can be tricky. Sometimes, the healthcare organization may have specifically hard-coded some modifiers into certain types of patient visits. Adding too many modifiers may indicate overcoding, and using the wrong modifiers can lead to claim denials or even being flagged for fraud.
Certain modifiers require careful reflection on when to use them, particularly modifier 25, which indicates an Evaluation & Management (E/M) service. This is a modifier for Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service, which allows for separate reimbursement for extra service performed above and beyond the primary care or procedure. This usually requires clear documentation to support the use of this modifier.
Another modifier that requires careful selection is modifier 59, which is Distinct Procedural Service. This modifier is often used to unbundle procedures which may be bundled together, to seek reimbursement for separate procedures that are done on the same day.
As you can imagine, using these modifiers can be very complex, and when used at inappropriate times, it can trigger compliance audits or claims denials for the healthcare provider.
The Documentation Doesn’t Match The Diagnosis
One thing that can trigger denials is when the ICD-10-CM codes don’t match the notes for the patient visit. Imagine if the codes being entered don’t align with the work the provider did for the patient. This can cause the insurance companies to deny a claim. Be meticulous in choosing codes that fit the medical services that were delivered.
Gaps in Communication Between Coders and Providers
So much of medical coding is about clear communication and detailed documentation. The coder relies on precise communication from the provider. When they don’t understand what the physician wrote, they can misinterpret the procedures and treatments provided. High-quality medical coding and error-free claims require good communication. Make sure you are getting clear communication from your providers.
Missing HPI or Exam Details
If a patient visit is missing a History of Present Illness (HPI) this can be a red flag to the insurance payer. In fact, HPI documentation is necessary if you are using an Evaluation & Management code (E/M code). These are CPT® codes ranging from 99202 to 99499 that represent evaluating and managing patient health, such as a check-up. These can be added by any physician or qualified healthcare professional. It can be a red flag if the provider skips over key details or findings which would justify the level of service. These are still required for a fully documented note. The medical coder should ask the provider for an addendum or documentation.
Diagnosis Doesn’t Match the Documentation
Do the provider notes have conflicting notes? This is a red flag which can affect claim approvals. For example, does the documentation say one thing, but the diagnosis doesn’t match up. When there is a mismatch, this can cause payers to flag the claim, cause coding inaccuracies, and cause delays in reimbursement.
Is the Office Using Outdated Coding Standards?
Medical coding standards are always being updated, ICD codes get updated editions from time to time. CPT® codes and HCPCS codes get updated even more regularly. If your team is coding using outdated codes, you might be missing out on more specific codes. This can actually be a compliance issue, and it also may cause claims to be denied or underpaid. Old coding standards can be good for a historical reference, but it’s very important to be using the most recent medical codes to ensure claims are processed and paid quickly without friction.
Using Too Many Unspecified Codes
Using Not Otherwise Specified (NOS) or Not Elsewhere Classified (NEC) codes too often can indicate the coding is not being done as accurately as possible. Having a deep familiarity with current coding standards will keep your claims from being flagged and help your medical coding remain compliant.
Not Auditing the Coding
Organizations sometimes outsource medical coding to third-party companies. There can be a repetitive cadence to the coding where similar codes are selected quite often. But are those codes really the best matches for the services provided? Even if your medical office does medical coding in-house, the coding should be audited regularly to make sure the right codes are being selected. This can help ensure the revenue cycle continues smoothly without underpayment or overpayment, while avoiding claim denials.
Using Inappropriate Codes & Upcoding
Upcoding is a phrase that describes the practice of always using the highest-level medical codes that result in the biggest reimbursements. This can happen in specialized fields of medicine where the E/M services are complex or time based. Though it is not a widespread practice, there are cases where private practices will incentivize medical coders to submit codes that produce bigger payouts. An example would be submitting codes for half-hour evaluations, when the consultation is only fifteen minutes long. Another example would be making the procedures seem more complex or intensive than they were in reality. Upcoding is very risky for the provider, and they can be fined or even excluded from government payment programs like Medicare and Medicaid. Upcoding is dishonest, and carries serious consequences. The best policy is to code accurately, based on the condition of the patient and not the provider specialty.
Overusing Modifier 22
One of the modifiers that can be overused is modifier 22, Increased Procedural Services. This is a modifier that indicates increased complexity in an otherwise routine procedure. Modifier 22 means the provider did extra work, above and beyond, for which they can seek extra compensation. As in every case, detailed and thorough documentation must be included to use this modifier.
Is the Healthcare Organization Looking at Denial Reports?
A large number of claims denials can indicate coding inaccuracies, and a deeper audit into procedural coding practices may be warranted. Claims denials can underscore a problem with medical coding that can lead to lost revenue. These shouldn’t be ignored, rather the organization should do a deep dive to find the cause of denials and create more efficient medical coding processes.
You can Become a Medical Biller and Coder at Campus Sacramento
If you’ve decided that medical billing and coding is your next career path, Campus Sacramento has an excellent Online Medical Billing and Coding program to help you get the certification you need. In less than ten months, you will be ready to take any of the nationally recognized initial medical coding and medical billing certification exams. If you’re ready to take the first step towards a rewarding career, or if you just need more information, contact our helpful Admissions team at 888-675-2460.