Medical billing in general is pretty easy stuff. These days, most bills go out automatically, priced and coded. Where problems occur is when the coding is off; it either delays bills going out or it causes insurance companies to reject them, which affects cash collection.

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Incorrect coding crosses many borders. It could be medical records; it could be the charge master. It could be physicians or certain ancillary (revenue generating) departments.

I’ve previously written about claims not being paid for other reasons, and I’ve touched upon coding issues but without going into any detail. This time I’m naming five issues I know occur most often that most billing departments aren’t often taught, thus never know to look at when claims get denied.

1. Endoscopic charges

Endoscopy is one of the toughest areas to capture properly. The problem is because way too often what’s recorded in the medical record isn’t what the physician either did or didn’t do. This causes an issue with medical records because by law they have to code what’s in the record and thus there are different codes for almost the same thing.

That’s because endoscopic procedures can be performed many different ways and there are often confusing charge descriptions that may not match up with the proper codes. Medical records doesn’t see charge codes, so they don’t know they’re not matching up unless the billing department is sharp and brings it to their attention… after the claim has been denied.

2. Lab services

Everyone has had lab services performed on them. Many lab bills end up getting denied because the procedures physicians request don’t match up with the diagnosis codes they’re sending over. Sometimes the issue is a physician requesting a procedure that’s part of a panel they’ve already requested. Sometimes they’re looking for multiple things but only send a diagnosis code for one of them. Some insurance companies will pay a portion of a claim while denying the rest, while others will deny the entire claim and leave billing trying to figure out what’s wrong.

3. Insufficient coding

I’ve seen different ways this one affects billing and patients getting their claims paid properly… if at all.

One way I’ve seen it is when physicians don’t code a claim describing what’s going on with a patient as opposed to coding just the procedure. There are many procedures that insurance companies believe are cosmetic when there’s actually a pain or dangerous component regarding the need for the service, and they deny coverage of the procedure.

This one personally happened to me when I had to have breast surgery to remove a painful lump and the initial procedure code made it look like it was a cosmetic procedure. I called the insurance company and explained that it was to relieve pain after a number of years and I was given two secondary codes to pass on to the physician so it would be covered in full; whew!

Another thing I’ve seen is when medical records doesn’t code claims showing all the diagnosis codes that a patient has, even if it seems to have nothing to do with the reason they’re an inpatient in the hospital. Since hospitals are paid based on diagnosis, sometimes reimbursement is reduced because the medical record doesn’t specifically link the reason a person is in the hospital to a pre-existing condition, even though the two things are medically linked.

The final thing I’ll mention is that there are procedures performed where the insurance company is expecting a secondary component to the procedure that’s missing. It could be a time component; it could be missing supplies; or it could be missing pharmaceuticals. These are items that will either get claims paid less or denied outright.

4. Diagnosis/revenue codes don’t match the patient or medical record

These are outright errors in coding that, because bills automatically go out electronically, gets missed more often than you’d expect. Things like men coded for pregnancy and women coded for prostate cancer are mistakes that cause reimbursement delays.

Other issues include charges with time components not recorded in the medical record, insufficient physicians notes, mixed records because of similar names or dates of birth, and of course procedure codes selected for billing not going through the computer correctly based on description, proper department or revenue codes.

5. Not updating charge master to new procedure codes

Every year there are updated charges along with new charges and discontinued charges. Sometimes the changes are subtle; other times there’s a drastic change that’s taken place. It’s been estimated that hospitals without a person whose main job is taking care of their charge master only review it every 5 to 7 years; can you imagine how much lost revenue and reimbursement that type of thing can cause?

A good example is what happened to some radiology codes in 2017. An entire range of angiography codes, from 75791 – 75978, were deleted and moved into the surgical code area and recoded from 36901 to 36906. These procedures were always up for grabs between radiology and the surgical area so having them finally solidified isn’t all that shocking, but if hospitals haven’t picked up on the change they’re not only losing reimbursement but could indirectly be accused of billing fraud; talk about scary!

There are lots more errors but these are some of the biggest that, if corrected, will get the biggest bang for your buck.

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