A good way to insure you’re avoiding denials and getting your claims paid the first time is to make sure you’re not making one of the ten biggest coding mistakes. Check this list to be sure you’re using best practices:
1. Hoarding old coding books
While it is okay to keep your old coding books as reference material, no one should ever use an old coding book. Each year, purchase new CPT, HCPCS and ICD-9 books. Even if a practice has electronic versions of these codes built into their software, the editorial and instructional materials in the CPT and ICD-9 books are not generally easily available electronically. Buy a new set of books, and read the editorial content at the start of each section for the services the practice offers.
2. Ignoring the editorial comments in the CPT book
The answers to many vexing coding questions are at the fingertips of all coders, billers and physicians. The answers are hiding in plain sight–in the editorial comments at the start of each section. Can you bill for an initial hospital service when admitting a mom-to-be in labor? Look no farther than the introductory comments to the Maternity section in your CPT book. If a physician bills for a preventive service and a problem-oriented visit on the same day, is the modifier appended to the preventive service or the problem-oriented visit? Find the answer in the editorial comments at the start of preventive medicine.
3. Clinging to long-held beliefs
Codes change. Rules are revised. Memory fails. Consult source documents frequently. Two useful source documents for physician practices are the CPT book and the CPT Assistant. For Medicare rules, download Chapter 12 of the Medicare Claims Processing Manual (100-04), which can be found at http://www.cms.gov/Manuals/IOM/list.asp.
4. Failing to link CPT and ICD-9 codes
Physician services are paid based on the fee levels associated with CPT codes. But payers deny claims based on diagnosis codes if the diagnosis does not support the medical necessity of the service or is not a covered indication for that service. Clinicians need to match the diagnosis code to the correct CPT code. This is particularly important for diagnostic tests and some Medicare preventive medicine services.
5. Neglecting to bill both an administration code and a medication code for an injection
When a patient receives a therapeutic injection or immunization or allergy shot, bill for the medication if the practice purchased it. If the state provided the serum or the patient brought it with them, bill only for the administration. Double-check these claims. If an administration code is charged, look for the medication. Many groups post the vaccines provided by the state without a charge.
6. Forgetting modifier 25
Modifier 25 is used to indicate that a separate, significantly identifiable E/M service was performed on the same day as a procedure. Failing to add the modifier to the E/M service or mistakenly adding it to the surgical procedure will result in a denied claim.
7. Abusing modifier 25
Beware the person who knows how to get a claim paid. “Just add modifier 25 to all of the E/M services. We don’t have time to look at the notes.” Appending modifier 25 will result in both the E/M service and the procedure being paid, so be sure that the person who selects the modifier knows the rules.
Medicare and some other payers restrict the use of an office visit with minor skin procedures. The National Correct Coding Initiative (NCCI) says:
“The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25.” (Chapter 11, Letter R.)
8. Confusing modifiers 51 and 59
Modifier 51 is used to indicate that the physician did two procedures on one day, and the second is not a component code of the first. Most Medicare payers do not require modifier 51 on claims. Modifier 59 is used to indicate that the physician performed a second procedure, which is bundled into the first and meets the requirements of a separate, distinct service. Access to the NCCI edits is critical.
9. Sloppy diagnosis coding
Non-specific diagnosis codes are the result of relying too heavily on pre-printed encounter forms or lists of favorites. There are two unfortunate results: The first is denied claims. The second is a more subtle and long term effect: When payers calculate the acuity of the practice for risk based contracting, they base that formulation on the diagnosis codes submitted on claims. Non-specific diagnosis coding results in decreased reimbursement.
10. Basing code selection on abbreviated descriptions
Whether it’s a paper encounter form or electronic charging in an Electronic Health Record, abbreviated descriptions are an invitation to incorrect code selection, particularly for minor surgical procedures and medications.
Betsy Nicoletti is the founder of Codapedia.com, a source of free coding advice for physician practices and is a nationally known consultant and speaker. She can be reached at firstname.lastname@example.org Watch a complimentary recorded webinar featuring Betsy speaking on Medical Billing Compliance – How to Keep CMS Out of Your Business now.