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Enhancing RCM Efficiency by Resolving Coding Discrepancies

4 Crucial Medical Coding Pitfalls To Avoid

“It’s very frustrating; healthcare is the only industry where you don’t know what it’s going to cost until it’s done.”  So said a frustrated victim of heart palpitations, who ironically felt he was a bigger victim of a medical coding error, as he was made to pay more than $6000 out-of-pocket expenses as a result of this some time in the middle of 2012.


It is an open secret that medical coding errors are at the core of many a billing issue that drive both providers and patients up the wall.  In big hospitals, as many as 250 personnel may be involved in the generation of a single medical bill.

Although this number might be reduced by a factor of almost 20 for very small clinics, it does indicate that the worlds of medical coding and medical billing often times appear as complex as the world of medicine itself.  “It all comes down to human beings being involved in a process that is very complicated,” says Kevin Theiss, a vice president at Summa Health System, headquartered in Akron, OH.  Mr. Theiss directly supervises an operation that generates close to a million medical bills a year.

An interesting study by a professor of health finance at the University of Minnesota found out that:

a.  40 percent of claim statements passed back and forth between providers and payers have errors.

b. Nearly 20% of the processed claims providers get back from insurance companies have errors.

c. 15% of all claims have fraud, negligence and abuse.


A.  It was seen that in 2011, in Northern Ohio more than 2500 bankruptcy cases were filed by low-income groups, citing mainly medical debts as the primary culprit.

But the impact is not just on patients alone, as the below statistic shows:

B.  The AMA in 2011 claimed that it cost providers $17 billion in backend processes due to what it claimed dubious payer payment criteria, with a special focus on medical coding.

So, with such a huge economic impact, it is only natural that federal audits to smoke out medical coding errors are going to increase.  And of course the Patient Protection and Affordable Care Act will only intensify the focus.  So, although there are a zillion things that might be set right when it comes to medical coding errors, the journey of a thousand miles always begins with that first step, in this case 4 steps to be exact:

4 Crucial Medical Coding Pitfalls To Avoid:

1.  Errant Use of Modifiers:  These are 2-digit alphanumeric characters added to codes that inform the payer of extraordinary circumstances.  There are CPT modifiers and there are HCPCS modifiers; developed by AMA and CMS respectively.   Many reasons exist for their incorrect usage; it could be erroneous data, plain misunderstanding, or just a desire to get that crucial reimbursement.  But it is important to understand that a clinic’s medical billing staff may only be adding fuel to the fire by getting this crucial aspect of medical coding wrong.

2. Choosing the Wrong CPT Procedure Code:  There are greater than 75,000 CPT codes; and a billion rules governing their usage.  Anyone can do the math that this is a recipe for disaster or at least major errors most of the times.  So anyone may get confused; but when you add to it the add-on exacerbating factors of incomplete encounter forms, incomplete medical records, or EHR malfunction it only increases the probability of a wrong code being chosen.  Thus the coder needs to be always focused and the clinic always needs to get those supplemental factors working.

3.  Wrong Usage of CPT code 99211:  It has been made abundantly clear that services like allergy shot, venipuncture, etc should not be billed as nurse visits but should be bundled into injection codes.  Vital signs monitoring by nurses before and after such services are considered part of the payment for such administrations but not a separate service by a nurse, capable of being billed as 99211.   Only established patients for whom there is a medical necessity for vital signs check, e.g. a hypertensive patient, may be billed as 99211.

Also there may be instances where usage of 99211 is appropriate than higher level E/M codes; 99212-99215; e.g. an internist performs a very simple service, which does not fulfil the criteria of the higher level E/M codes.  Only a knowledgeable medical coding workforce may get the above right at all times.

4.   Proper Linkage of Diagnosis Codes (ICD-9/ICD-10) to CPT Codes:  The medical claim should make it very clear to the payer as to why a particular service was rendered; more so in circumstances where multiple unrelated services are done.

E.g. a patient visiting his physician for spirometric tests for asthma might undergo a routine abdominal ultrasound for GERD.  In such an instance the PFTs done should be linked to asthma while the ultrasound linked to the GERD.  Else the chances of claims rejection are high.

The above is just the tip of the medical coding iceberg; and if a clinic finds out that their medical coding workforce may be too inexperienced to get the above right at all times, then it may be high time that they seek out the services of a dedicated medical billing or medical coding vendor.

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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