Medical coding and billing involve complex processes that can differ depending on the patient, insurer and procedure. Even the most diligent financial services departments experience claim denials, but knowing the most common mistakes can help you take steps to avoid them.
Here, we discuss the first five most common medical coding and billing mistakes that cause claim denials so you can avoid them in your business:
1. Claim is not specific enough. Each diagnosis must be coded to the highest level for that code (the maximum number of digits for the code being used).For example, the diagnosis for hypertension begins with 401, but it requires a fourth digit (e.g., 401.0 is malignant essential hypertension). Similarly, the code for diabetes requires a fifth digit. The code for diabetes is 250.0, and the fifth digit indicates the type of diabetes (e.g., 250.00 diabetes mellitus type one).
2. Claim is missing information. Any missing information may be cause for a denial, but the items are: date of accident, date of medical emergency and date of onset. Be sure to scrutinize all claims for missed fields and required supporting documentation.
3. Claim not filed on time. If a proper claim is submitted, but it’s not within the timing window, it may result in a denial. Medicare providers should be aware that the Affordable Care Act reduced the claims-submittal period from between 15 and 27 months down to 12 months. The start date for a Medicare claim is the date the service is provided to the patient or the “From” date on the claim form. The claim must be received by the appropriate Medicare claims processing contractor prior to the end date (exactly one calendar year after the start date). If a claim is sent prior to the end date but received after, it will be denied. It is vital that you understand the process in addressing timely issues. The understanding of what to submit for supporting documentation to receive reimbursement is critical to appealing timely issues. You will not be reimbursed for the services denied timely if you do not understand how to handle them. Commercial and Medicare have different guidelines that are considered timely filing. Per Section 6404 of the Patient Protection and Affordable Care Act (ACA), Medicare fee-for-service (FFS) claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. Claims with dates of service January 1, 2010, and later received more than one calendar year (12 months) beyond the date of service will be denied and/or rejected as being past the timely filing deadline.
Other Key Points of Medicare Change Request 7080:
· For institutional claims that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim will be used to determine the date of service for claims filing timeliness.
· For professional claims (CMS-1500 Form and 837P) submitted by physicians and other suppliers that include span dates of service, the line item “From” date will be used to determine the date of service and filing timeliness. (This includes supplies and rental items). BE AWARE: If a line item “From” date is not timely, but the “To” date is timely, Medicare contractors will split the line item and deny untimely services as not timely filed.
4. Incorrect patient identifier information. To avoid this error, make sure the patient’s name is spelled correctly, the date of birth and sex are accurate, the correct insurance payer is entered and the policy number is valid. It’s also a good idea to check whether or not the claim requires a group number, the patient’s relationship to the insured is accurate, and the diagnosis code matches the procedure performed. Finally, make sure the primary insurance is listed as such in the case of multiple insurances.
5. Coding issues. If you are using an outdated codebook or your coder or biller enters the wrong code, your claim could be denied. The use of outdated coding books either CPT (Current Procedural Terminology), ICD-9 (International Classification of Diseases) or (Healthcare Common Procedure Coding System) HCPCS and/or super bills will result in loss of revenue. Insufficient documentation occurs when documentation is inadequate to support payment for the services billed or when a specific required documentation element is missing. When coding and submitting claims it is imperative that what is documented is billed. If it is not documented carriers, consider the service(s) were not performed. However, denials related to insufficient documentation, no documentation, and medical necessities are more complicated because providers must be involved in improving the process. Coders unequivocally play a key role in denials avoidance, and they are best suited to proactively identify process deficiencies by using a proactive not reactive approach. The follow ruling is important to understand how carriers look at errors in billing. Striving to be proactive not reactive to any concerns and wanting to be sure that practices do not ever fall into the violation of 18 U.S.C. § 1347. Under that code section, it is a felony to knowingly defraud any health benefit program or to fraudulently receive payment from any health benefit program, and/or under 18 U.S.C. § 1035, which makes it a felony to willfully make fraudulent statements or representations in connection with the receipt of payments for health care benefits. This is nothing that a practice would ever knowingly do but not using correct billing, procedures and protocols could put you at risk. The practice should take no comfort in claiming lack of knowledge or that they were mistaken about the law should audits occur. The statutes governing health care fraud do not provide leniency for a provider’s lack of knowledge therefore protocols should be in place for your office to make sure should you have an audit that you have mitigated your risk and liability.
To help keep errors to a minimum, consider using a qualified medical coding and billing company that supports your needs.