What Type of Mistakes Do Medical Coders Make?

What Type of Mistakes Do Medical Coders Make?

When it comes to filling out insurance claim forms, medical coders and billers need to be as accurate as possible in the coding they use. The experts at Find-A-Code.com say that irrespective of whether they are filling in ICD 10 or CPT codes, accuracy is absolutely vital. A wrong code could result in a payment being rejected or declined completely, which can have disastrous consequences for the medical facility or the individual patient. 

Although there is a massive emphasis on accurate coding, incorrect coding is not the only type of mistake made on insurance claim forms. The following are a few examples:

Missing Data

Insurance claims are often sent back to be corrected because they have missing data. This can happen when a coder comes across a patient file with missing information. They might decide to put the form to one side with the intention of asking the physician for clarification later. For whatever reason, the coder might forget to do this or someone else might collect the form and send it away without checking. Sometimes, digits are omitted from codes, or a diagnosis code may not have been correctly linked to the CPT code. Whatever the reason for the missing information, the claim will not be processed and will usually be sent back to be amended. While rejected claims are preferable to outright denied claims, they still cause delays with payment. This can then have a knock-on effect. 

Invalid Codes

Those who have been coding for many years will inevitably have certain codes memorized. However, coding can and does change quite frequently, so it may be the case that some of the memorized codes have been altered, or even deleted completely. It is up to the coder to double check codes on claims forms before sending them away. 

Under-Coding

Under-coding occurs when a coder bills for a treatment that is less expensive than the one that was carried out. Although this can often occur accidentally, it is sometimes done deliberately by a medical provider hoping to avoid an audit. 

Up-Coding

Again, up-coding can occur accidentally by coders new to the job, but it can also be done deliberately if the medical facility is hoping to receive a higher payment for a more expensive treatment than the one that was actually carried out. Both under- and up-coding are considered fraudulent. 

Unbundling

There are some procedures and treatments that are bundled together under one specific code because they are all related to the same condition. Nevertheless, sometimes coders will bill for each specific treatment or service, which means a higher reimbursement for the medical facility. This is a fraudulent practice. 

Services Not Performed

Mistakes happen and sometimes an additional procedure that was not performed is billed to the insurance provider. It could be the result of a slip of the finger when inputting data; this will usually be easily noticed because the service does not relate to any of the other codes on the bill. However, it may be a deliberate act to get a higher payment from the insurance company. 

The Importance of Preventing Coding Mistakes

Medical coding needs to be accurate and the best way to avoid errors is to ensure that all forms are double-checked before they are sent for reimbursement. Managers of medical facilities need to implement strategies to cut down on mistakes that could be costly in terms of rejected or denied claims or, worse, financial penalties. 

Any mistakes that are considered to be fraudulent will likely result in criminal charges brought against the medical facility and/or the individual coder.

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