In this two-part series, we discuss how medical coding and billing involve complex processes that can differ based 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. These top coding, billing, and filing errors are a digest of actual clearinghouse data derived from millions of medical claims.

5 of the 10 most common medical coding and billing mistakes that cause claim denials are

5 reason for claim denials
1. Coding 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, in ICD-9, essential hypertension was coded using 401.0 (malignant), 401.1 (benign), or 401.9 (unspecified). In ICD-10 however, the code is I10. Essential (primary) hypertension in ICD-9, 401.0 includes “high blood pressure” but does not include elevated blood pressure without a diagnosis of hypertension. In ICD-10, this is R03.0
Similarly, in ICD-9 the code for diabetes was 250.0, and the fifth digit indicates the type of diabetes. In ICD-10 the equivalent code is E10.649.

2. Claim is missing information.

Any missing information may be cause for a denial, but the most common missing items are: date of accident, date of medical emergency and date of onset. Be sure to scrutinize all claims for missed fields and attach all 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 – 27 months down to 12 months. The start date for a Medicare claim is the date the service was provided 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 (12 months after the start date). A claim sent prior to the end date but received after will be denied. It is critical to understand required supporting documentation to receive reimbursement. 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 filings.

Other Key Points of Medicare Change Request 7080:
  • For institutional claims that include span dates of service ( “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).
    Note: 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 DOB and sex are accurate. Also make sure that the correct insurance payer is entered, and the policy number is valid. It’s also a good idea to check whether 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 your 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), (Healthcare Common Procedure Coding System) HCPCS 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 required document 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) as not performed. However, denials related to 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 use a proactive approach.

The follow ruling is important to understand how carriers look at errors in billing. Strive to be proactive to any concerns and make sure that practices do not violate 18 U.S.C. § 1347. Under that section, it is a felony to knowingly defraud any health benefit program or to fraudulently receive payment from any health benefit program. Under §1035, it is a felony to willfully make fraudulent representations in connection with the receipt of health care payments. Even unknowingly, 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 that you have mitigated your risk and liability.

Read the next five common medical billing and coding mistakes in our next post here. To help keep errors to a minimum, consider using a medical coding and billing software that supports your needs. Learn more about PracticeSuite today.

Last Updated on August 11, 2022


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