Medical billers and coders are crucial to the healthcare industry. They keep doctors and nurses on track and organized by carefully documenting patient procedures and treatments. In addition, they submit bills to insurance companies, which then pay claims. When a medical biller or coder makes a mistake, it can delay the claims process, cause a loss of revenue and/or affect a patient’s care.
It’s inevitable that errors occur – especially when dealing with the thousands of codes a medical biller or coder is expected to know. The World Health Organization created the International Classification of Diseases, Tenth Revision (ICD-10), which universally classifies and codes all diagnoses, symptoms and medical procedures. The ICD-10 codes that you, as a medical coder, use make it easy to share and compare patient medical information among various hospitals, regions and providers. They also ensure that the procedure that is billed makes sense with the diagnosis. There is a lot of information to know.
Add CPT® codes, the five-character Current Procedural Terminology codes that are the U.S. standard for the way medical professionals document and report medical, surgical, laboratory, radiology, anesthesiology and E/M (evaluation and management) services, to the equation, and the coder’s job becomes even more complex, with a greater chance for making mistakes.
Knowing the more common problems with coding and billing, and understanding how to avoid them, is key to efficiency in the job.
Here are a few of the more common problems faced by medical billers and coders:
Poor or missing documentation
Sometimes a provider doesn’t give enough information about a procedure, leaves important items out or enters information that is illegible. Unless the coder or biller is able to consult directly with the provider and clarify the situation, a claim request may be submitted incorrectly.
Rejected or denied claims
If a claim request has been submitted incorrectly, resulting in errors found before it is processed, the insurance company will reject the claim and not pay the bill as written. It’s then sent back with an explanation, and the process begins again. In another scenario, a claim may be denied if the payer determines the procedure or charge is not payable. Perhaps it violates the payer-patient contract (i.e., using an out-of-network provider) or is a high-tier prescription that is not covered. A denied claim can be appealed, but such an appeal takes time and can be expensive.
Under- or upcoding
These errors are often intentional and considered to be fraudulent. Under-coding involves reporting less-expensive medical services than the ones that were actually performed. Over-coding is the opposite, and it is a means for trying to receive higher reimbursement than a provider is entitled to.
This, too, is intentional and fraudulent. It’s similar to upcoding, in that it involves charging procedures separately so that the provider receives a greater payout.
Medical billing and coding require attention to detail, but sometimes negligence causes clerical errors with:
- Patient data (wrong name, date of birth, insurance company)
- Provider details (incorrect address, name, contact information)
- Insurance information (wrong policy number, address)
- Confusing codes (too few or too many digits, wrong modifiers, place of service discrepancies)
- Mismatched codes (entering ICD-10 codes with CPT or vice versa)
- Omitting procedural codes
- Duplicate billing (submitting claims without checking to see if the service had already been paid or reported)
Although these errors are fairly common, they can be expensive. According to Healthcare Business and Technology, doctors lose $125 billion each year because of poor medical billing systems and errors. Most errors can be avoided if the medical coder or biller takes a few simple steps:
- Stay current and on top of code changes. ICD-10 and CPT code manuals are updated annually. Also, if you’re a member of American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA), you are required to complete education credits every two years to help you remain current.
- Be diligent and check your work. Make sure you didn’t add an extra digit or report an incorrect code. Also, verify patient, provider and insurance information.
- Communicate any concerns or questions so that you can note correct information. Doctors sometimes take hasty notes that may be difficult to read. If you’re unsure about a procedure or treatment, ask.
- Follow through to make sure that information was submitted and that claims were paid correctly and in a timely fashion. If a claim is rejected or denied, make sure that the payer included an explanation of benefits (EOB).
Partially because of a rapidly aging U.S. population, healthcare jobs are in demand because as people age, they usually need more medical care. According to the Bureau of Labor Statistics, the employment rate for medical records and health information technicians (billers and coders) is growing much faster than the average for other occupations because people in these jobs are the ones who handle insurance and patient claims.
MTI College offers a Medical Billing and Coding Professional Diploma Program that can prepare you to enter this in-demand field. When you study at MTI College, you train for both positions. Upon graduation from the program, you could be working alongside doctors and nurses in a hospital, doctor’s office, clinic, nursing home or other medical facility, using your skills to provide much-needed assistance.
MTI College’s Medical Billing and Coding Training Program gives you the background you need to enter the exciting, busy world of healthcare. Contact MTI College Sacramento today to jump-start your career.