Don’t Let These Coding Mistakes Cost Your Practice

Medical Coding, Medical Billing, Medical Coding Errors and Mistakes, Medical Coding Strategies

Upcoding, downcoding, and miscoding errors cost billions of dollars each year, according to a study of coding errors by the California Medicaid payer Medi-Cal. The study showed that the agency had paid more than $1 billion in inappropriate claims caused by incorrect reporting of codes — which providers had to repay.

Documentation and Service Level Must Agree

Upcoding was the most common error in this study, where a practice bills for a service at a higher level than the documentation warrants. For example, a provider reported 99245 (Office consultation for a new or established patient, which requires these 3 key components…). For this code, physician documentation must indicate medical decision making of high complexity, with a comprehensive patient history and physical exam. But if you reported this code with accompanying documentation indicating an “unremarkable” history and a “problem-focused examination of the abdomen,” the payer would deny the claim because documentation supports only a low complexity of medical decision making. You would have to resubmit, using the straightforward medical decision-making code 99241 (Office consultation for a new or established patient, which requires these 3 key components…).

Ensure Medical Necessity – Document Correctly

Inadequate medical record documentation often includes a failure to document medical necessity. For example, documentation consisting only of the phrase “office visit for otitis media recheck,” with no date of service, explanation of exam, history of present illness, or other details will lead to trouble during an audit. With so much information missing, the submitted documentation shows nothing the provider did for the patient to support the coding choices.

Incorrectly documenting a service causes problems, too. For example, a physician reported 69210 (Removal impacted cerumen requiring instrumentation, unilateral). Medicaid paid the charge, but review of the records later on revealed that the doctor was simply moving ear wax aside to view the ear drum, not removing an impaction. The practice had to pay back the MAC.

Whoops, We Don’t Cover That!

Sometimes payers will mistakenly pay you for a service that they don’t cover. For example, a provider performed an E/M telephone service and reported 99442 (Telephone evaluation and management service by a physician or other qualified health care professional…). This was the right code, but it was for a service this payer’s policy does not cover. The provider had to return the payment. Payer edits will usually prevent improper payment of noncovered codes, but this example proves that’s not always the case.

Don’t Forget to Sign the Lab Order!

Reviewers found other errors no one could blame on coding.. For example, a provider saw a patient, suspected a urinary tract infection, and ordered a urinalysis, but didn’t sign the lab order, rendering the service not payable.

Does CMS Owe You Money?

Medicare errors sometimes mean that the government owes practices money. A recent CMS Comprehensive Error Rate Testing (CERT) report showed that CMS still owes $1.4 billion to providers it underpaid in 2013. CMS’s CERT program reviews more than 40,000 claims submitted to Part A and B Medicare Administrative Contractors (MACs) and MACs handling durable medical equipment (DMACs) during each reporting period. CMS emphasizes that CERT program rates are not the same as fraud rates, but rather are a measurement of payments that didn’t meet Medicare’s requirements.

Medicare auditors create CERT reports by reviewing claims in search of missing or insufficient documentation, incorrect coding, and medically unnecessary services. In some of the coding errors, providers shorted themselves by downcoding. Insufficient documentation caused many of the CERT report errors.

Send Auditors What They Need

Don’t make this mistake. Often CERT auditors will ask providers for a missing item, but when the practice responds, it just sends duplicate copies of records the auditors already have. If an auditor asks you for additional documentation, don’t resubmit information you already sent them. Take the time to track down the missing information and get it to the auditor as soon as possible. If you don’t, you could have to repay the MAC.

Incorrect Evaluation and Management (E/M) Claims Caused $3.9 Billion in Errors

CMS found that providers improperly billed $3.9 billion worth of E/M claims in 2014, often by submitting documentation supporting a different E/M level than what they billed. Other problems included lack of physician signature authentication and wrong place of service.

Don’t Forget to Sign the Op Report!

Medicare Learning Network (MLN) compliance newsletter reported the case of an orthopedic surgeon who billed for 22633 (Arthrodesis, combined posterior or posterolateral technique…). He submitted an operative report reporting lumbar fusion, decompression, implantation of biomechanical fixation device, and allograft bone placement for a date of service in February 2014, but he failed to sign the operative report and discharge summary. When the CERT medical reviewer requested a signature attestation that would have let Medicare pay the claim, the surgeon instead sent duplicate copies of the unsigned op report and discharge summary. Though the documentation supported the procedure’s medical necessity, the doctor’s failure to sign the op report and discharge summary caused the reviewer to deny the claim because of insufficient documentation. Without the signature, there was no proof that the surgeon had performed the service.

In-House Compliance Audits Reduce Coding Errors

To fix this type of error before outside auditors find them, do your own in-house compliance audits, says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel. Dr. Weinstein also advises practices to audit notes for the medical necessity of the level of service they claim. If you’re called for an outside audit, pull all encounters selected for the audit, including all accompanying documentation, making sure everything is there. If you discover issues, don’t alter documentation, change billing records, destroy records, or compromise the information in any way. When in doubt, contact your practice’s attorney for help in presenting the missing information to the auditor.

What’s Your Experience With Audits?

If you’ve been doing your own audits, what triumphs — or trials — have you experienced? We would love to hear your experience. Write us a note in the comment box below.

Ease Your E/M Audit Chores With SuperCoder’s EM Auditor

Looking for ways to increase E/M audit productivity and coding accuracy but tired of the paperwork nightmare? Want to be sure codes comply with E/M guidelines? Automate that tedious E/M auditing with SuperCoder’s EM Auditor. Quick screen navigation gives options to assign levels to the key components or time, helpful for both coding and auditing. You can even choose between the 1995 and 1997 E/M guidelines to let EM Auditor tell you if reimbursement would be higher using a different guideline. Get the details of what this product can do for you today by checking out the EM Auditor product demo screencasts!


Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

, , ,

Leave a Reply