IN TODAY'S HE ALTHCARE ENVIRONMENT, IT IS IMPER ATIVE TO ENSURE YOUR MEDICAL PR ACTICE
PERFORMS ITS BILLING AND CODING FUNCTION AT THE HIGHEST LE VEL POSSIBLE.
IN MANY CASES, billing and coding mis-
takes can cause revenue to decrease; they
could also result in overpayments. Either
way, these mistakes could be costly.
Let's first address the common billing
and coding mistakes that occur in a medical
o¨ce, and then we will review the conse-
quences for these mistakes.
The revenue cycle begins when your
front desk staff initially talks with the
patient and schedules the appointment.
Part of this important phone conversa-
tion is to obtain the patient's insurance
information to ensure the patient's insur-
ance coverage is in eect, and to learn the
patient's responsibility for copayments,
deductibles a nd other out-of-pocket
expenses. Incorrect insurance informa-
tion can delay care, because the patient's
insurance information cannot be verified
prior to being seen, and payment, if the
patient was seen without having his or
her insurance information verified. If the
medical record does not document the
services provided or the reason for medi-
cal necessity, the claim could be initially
denied, or perhaps only a few of the CPT
codes will be paid, while other CPT codes
receive a "zero payment." What does your
sta do when they receive an explanation
of benefits (EOB) notice with a "zero pay-
ment"? Do they post this on the patient's
billing record as a write-o/adjustment, or
do they contact the insurance payer to ask
why the CPT code was not paid?
Other common mistakes include using
outdated or incorrect CPT and ICD codes
or not using modifiers when needed. Each of
these mistakes could aect the payment to
your medical practice. While the amount of
the incorrect payment may be small, these
small amounts could have a huge impact
over a period of time. A s a n exa mple,
based on the 2016 Medicare Part B Fee
Schedule for the San Antonio area, the
dierence in payment between a 99213
and 99214 is approximately $33. While
$33 may not seem li ke a sig nif ica nt
amount, consider if this dierence were
based on 200 patients. The dierence
then becomes $6,600. Just as under-
coding has a negative eect, over-coding
can have consequences, such as an audit
performed by the insurance payer.
Incorrect billing and coding practices
ca n create compla ints from patients
who feel the medica l practice may have
overcharged for the visit. If this occurs,
hopef u l ly a pat ient w i l l cont a ct t he
practice a nd ask to spea k with a billing
representative or the practice manager;
however, t he patient cou ld compla in
directly to his or her insura nce com-
pa ny. Depending on the outcome of the
patient 's phone ca l l to the insura nce
compa ny, a nd if t he i nsura nce com-
pany received other patient complaints
about your practice, t h is cou ld tr ig-
ger a n audit a nd a l legation for f i ling
fraudulent cla ims. Audits ta ke time to
defend, a nd could result in the practice
having lega l bills to defend billing a nd
coding policies.
The media has printed a r ticles in the
past advising patients to review their
medica l bills to ensure they ref lect the
medica l ser vices provided. Refer to a
U.S . News & World Report a r ticle dated
Sept. 8, 2014, titled "6 Questions You
Should Ask Before Paying A ny Medica l
Bill." The article instructs the patient to
verif y the va rious ser vices listed were
actua lly provided, as well as other tips to
ensure they are being charged correctly.
Prevention and sta education are great
tools to implement and can help avoid
bi l l i n g a n d c o d i n g pr oblem s . Ho w
involved a re you in the billing process?
Do you meet reg ula rly with your prac-
tice ma nager to review repor ts, such as
write-offs and adjustments, denia ls and
appea ls, a nd precollection repor ts? We
recommend the physicia n leadership
meet w it h t heir practice ma na ger at
least monthly to discuss the f ina ncia l
hea lth of the practice.
Your medica l billing and coding com-
plia nce pla n shou ld address periodic
bi l ling a nd coding rev iews to ensure
you have sound policies and procedures.
These reviews ca n be conducted inter-
na lly or by an externa l company, such as
Concordis Practice Ma nagement LLC.
We wou ld be happy to ta l k w it h you
rega rding a billing a nd coding review,
which is per for med by our Cer tif ied
Professiona l Coders.
Visit Concordis Practice Management
LLC at concordispracticemgmt.com or
call 210-704-1014 for more information.
References:
1.
medpmr.com/the-five-negative-ešects-of-
medical-coding-and-billing-errors/
2. aafp.org/fpm/2011/0300/p31.html
3.
m e d i c a l o f f i c e . a b o u t . c o m / o d /
medicalbilling/a/The-Clean-Up-Crew.htm
4. m e d i c a l b i l l e r s a n d c o d e r s . c o m / b l o g /
how-medical-coding-mistakes-ašect-your-
revenue.html
5.
acrbulletin.org/acr-bulletin-september-
2014/165-claim-denials
6.
n o v i t a s - s o l u t i o n s . c o m / w e b c e n t e r/
portal/MedicareJH/FeeLookup?_afrLoo
p=2209931058059222#!%40%40%3F_
afrLoop%3D2209931058059222%26_adf.
ctrl-state%3D1bha86quw0_42
7.
m o n e y . u s n e w s . c o m / m o n e y / b l o g s /
my-money/2014/09/08/6-questions-you-
should-ask-before-paying-any-medical-bill ■
ARE CODING AND BILLING MISTAKES
BY DINA PETRUTSAS, CPA
Hurting Your Medical Practice?
P R A C T I C E M A N A G E M E N T 1 3
