In this article, we review mistakes made throughout the billing, documentation, and coding processes and what you can do to prevent them.
Coders, billers, and physicians are much more knowledgeable now than when we started working with practices over 25 years ago. There has also been a steady increase in automation throughout the billing, documentation, and coding process. Despite the increase in knowledge and increased use of automation, we continue to see many costly billing, documentation, and coding mistakes.
In this article, we will review mistakes made throughout these processes and what you can do to prevent them.
Access Project, a health care advocacy group, has determined that 80% of all medical bills contained mistakes, according to an Aug. 2, 2017 Medical Economics article, “Easy tips for physicians to reduce billing errors.” Kaiser Health reported that $68 billion is lost to health care spending because of medical billing mistakes.
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Billing rules and payer requirements have become more and more detailed and restrictive. The margins within which physician practices operate continue to decrease. Electronic medical records, practice management systems, and other automated tools used by practices require too much time and manual effort to use correctly. New quality and value programs are requiring more time and effort with little visible benefit to patient care or outcomes.
The health care field is in many ways no different than the broader market. As the system becomes more complex, practices have to continue to innovate, educate, and improve internal systems to keep up with both the clinical and administrative demands of the system. Like it or not, human interface is a key component. Input into the system must be accurate, and the outcome of the automated processes must be monitored to ensure that the information is correct. “Garbage-in/garbage-out” is applicable to today’s medical billing process.
In our work with practices around the country, we see mistakes being made in every step of the complicated and detailed process. Collecting patient data, identifying the services provided, accurate service documentation, determining the correct codes, submitting the claim, and accurate follow-through are a few of the common failure points in the process.
Today’s billing process requires a team effort in every practice. Many of you are familiar with what we’ve called the “Wheel of Fortune” detailing the 18 to 20 steps that are required to accurately code, bill, and collect.
Next: Common points of failure
Here are just a few examples of areas and actions that we see as common points of failure during the billing process.
Pre-service: Incorrect demographic data, inaccurate insurance/coverage information, prior authorization. Solution:
Encounter: Failure to report all services provided, incomplete documentation, inadequate communication from provider to billing department, and inaccurate coding, including the wrong level of evaluation and management service provided. Solution:
Billing: Improper modifier use. Two specific examples follow.
Example 1: Modifier –25 is both overused and underused due to a lack of understanding of how it should be used. Solution:
Example 2: Modifier –59 and the “X” modifiers. The problem here is overuse and misuse. Solution:
Follow-up: Automated posting is not an excuse to allow payers to process claims without review. Solution:
In summary, physicians, as leaders of the team, need to be more knowledgeable and more involved, and pay attention to the details. In addition, they need to demand excellence in education and performance by their entire team. Conducting periodic checkups is required. Being too busy taking care of patients and ignoring the business you run can be very costly.
Read: When can modifier –25 be used with an E/M code?
Physicians are very trusting and hire people that they know have the expertise to do the job. They don’t question their expertise or the jobs they’re doing. This is a good thing in many ways. However, to quote W.C. Fields: “Trust everyone, but cut the cards.” Each employee must be held accountable for their actions. The office needs to know that everyone who touches the many steps in the revenue cycle has the knowledge, expertise, and understanding of the tools and expectations to do their job. In addition, staff members should be encouraged to update and continue their education.
We encourage you to look at your data entry, documentation, billing, and collections in depth throughout the year. Whether you own the business or are employed, are “hands on” or are detached from the billing process, you are ultimately responsible for bills submitted in your name. The battle to end billing mistakes will require continued analysis, diligence, and leadership.
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The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
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