Money concordis management

Are Coding and Billing Mistakes Hurting your Medical Practice?

In today’s healthcare environment, it is imperative to ensure your medical practice performs their billing and coding function at the highest level possible.  In many cases, billing and coding mistakes can cause revenue to decrease; however, the mistakes could also result in overpayments. Either way, these mistakes could be costly in other ways. Let’s first address the common billing and coding mistakes that often occur in a medical office, and then we will review the consequences 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 conversation is to obtain the patient’s insurance information to ensure the patient’s insurance coverage is in effect, and learn the patient’s responsibility for copayments, deductibles, and other out of pocket expenses.  Incorrect insurance information can delay patient care because the patient’s insurance information cannot be verified prior to being seen, and delay payment if the patient was seen without having their insurance information verified.


If the medical record does not document the services provided or the reason for medical 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 staff do when they receive an explanation of benefits (EOB) notice with a ‘zero payment’?  Do they post this on the patient’s billing record as a write-off/adjustment or do they contact the insurance payer to ask why the CPT code was not paid?


Other common mistakes are using outdated CPT and ICD codes, not using the correct CPT or ICD codes, or not using modifiers when needed.  Each of these mistakes could affect the  payment to your medical practice.  While the amount of the incorrect payment may be a small amount, these small amounts could have a huge impact over a period of time.  As an example, based on the 2016 Medicare Part B Fee Schedule for the San Antonio area, the difference in payment between a 99213 and 99214 is approximately $33.00.  While $33.00 may not seem like a significant amount, consider if this difference were based on 200 patients… the difference is $6,600.00.  Just as under-coding has a negative effect, over-coding can have other consequences; such as having an audit performed by the insurance payer.

Incorrect billing and coding practices can create patient complaints because they feel the medical practice may have overcharged them for their visit.  If this occurs, hopefully the patient will contact the practice and ask to speak with a billing representative or the practice manager; however, the patient could complain directly to their insurance company.  Depending on the outcome of the patient’s phone call to their insurance company, and if the insurance company received other patient complaints about your practice, this could trigger an audit and allegation for filing fraudulent claims.  Audits take time to defend, and could result in the practice having legal bills to defend their billing and coding policies.

The media has printed articles in the past advising patients to review their medical bills to ensure they reflect the medical services provided.  Refer to a US News Report dated September 8, 2014, titled ‘6 Questions You Should Ask Before Paying Your Medical Bill’.  The article instructs the patient to ensure the various services listed were actually provided, as well as other tips to ensure they are being charged correctly.

Prevention and staff education are great tools to implement to avoid billing and coding problems.  How involved are you in the billing process?  Do you meet regularly with your practice manager to review reports, such as write-offs and adjustments, denials and appeals, and pre-collection reports?  We recommend the physician leadership meet with their practice manager at least monthly to discuss the financial health of the practice.

Your medical billing and coding compliance plan should address periodic billing and coding reviews to ensure you have sound policies and procedures.  These reviews can be conducted internally or by an external company, such as Concordis Practice Management, LLC. 

We would be happy to talk with you regarding a billing and coding review, which is performed by our Certified Professional Coders. Contact us today


No Comments

Post a Comment