Significantly improve reimbursement and cut down on denials by giving coding the attention it deserves. The following are common coding issues and their effect on your bottom line:
1. Inaccurate CPT-4 code or ICD-9 code. This occurs when the physician performs a procedure and does not list the correct ICD-9 code to support the notes and documentation. For example, suppose that a patient went to the doctor for common cold symptoms. During the visit the patient mentioned a wart, which the doctor removed. If the ICD-9 code only included the common cold, the physician risks not getting paid for the wart removal.
2. Inappropriate use of modifiers. This often occurs on evaluation and management (E/M) levels. If a patient visits a physician for preventative medicine and asks about a lump on his or her chest, this incorporates a sick-visit element to the charges. If you don’t include appropriate modifiers, you will not be properly reimbursed. Different plans have different requirements, so it is important to become familiar with the subtleties of each.
3. Improper coding links. If you don’t link ICD-9 codes with the appropriate CPT code, it could lead to a line-item rejection.
4. Coders versus data entry staff. If the code is off by one number or one digit is entered wrong into the computer system, the meaning of the intended code changes, which leads to problems with reimbursement..
5. Behavioral health carveouts. For example, many children receive treatment for attention deficit hyperactivity disorder, which falls into the behavioral health category. When a patient’s insurance plan has behavioral health carveouts, primary care providers are usually not participating providers. Straight preferred provider organizations are more likely to pay the physician, but HMOs tend to have carveout behavioral health companies.
Look at the explanations of benefits (EOB) and the handling codes on them to understand what’s happening to your claims. Tracking your EOBs helps you identify trends in denials.