Medical billing and coding errors are of different types. The impact of the consequences depends on the intensity of the error. However, any kind of errors result in a temporary denial of claims. This causes lots of discomfort to the patient as well as the healthcare provider in question. Some of the common billing and coding errors are described below:
Check Different Types Medical Billing And Coding Errors
Assumption coding is one of the common errors that results in temporary denial of a claim. This error occurs when the medial insurance specialist assumes that the patient was subjected to a standard treatment or standard procedure in order to treat a routine condition or illness. However, in reality, the procedure performed or the treatment given would be totally different. Nevertheless, the assumption results in a wrong medical billing and coding. In such cases, the claim is withheld until the hospital authorities submit proper supporting documents.
There are basically 3 levels of diagnosis codes. However, sometimes the medical insurance specialist omits one or two levels of codes. The first level is manifestation, the second is episode of care and the third is site of infliction. In case of a truncated coding, the insurance specialist may submit only the first or the second code.
At times there could be discrepancies in the information submitted by the medical insurance specialist. For instance, the gender may be recorded as a male and the medical procedure conducted would be recorded as a hysterectomy.
This happens when the medical insurance specialist fails to submit proper documents. Either the documents submitted are insufficient to sanction a claim or they might be the wrong ones. In such cases, the claim is held back until the submission of proper documents.
This occurs when the medical insurance specialist alters the documents or re-creates the actual documents in order to support the medical claim. This error amounts to a serious offense or fraud. In such cases, the healthcare provider has to face criminal or civil charges.
This occurs when the claim submitted is not complaint with the policies prescribed by the insurance company. For a single diagnosis if a patient is examined by two different doctors, then the claim cannot include both the physicians. If the claim is submitted for getting reimbursements on behalf of both the doctors then this amounts to noncompliance.
For certain medical procedures, the patient should seek a preapproval from the insurance company. This should be done before the healthcare provider undertakes any treatment procedure. If the claim is submitted after the conclusion of the procedure, then there is a good chance that the claim might be denied.
Up Coding/Down Coding
Sometimes the claim contains a procedure code which represents a higher amount than the medical procedure actually performed by the healthcare provider. This error is known as up coding. Such an error represents a criminal offence. It might even subject the healthcare provider to a detailed investigation. However, in most cases, the insurance company replaces the procedure code with a lower amount code and forwards the reimbursement. Similarly, in case of a down coding, the medical insurance specialist enters a procedure code that represents a lower amount than the actual medical procedure. This is sometimes done to avoid denial of the claim.
Sometimes the medical insurance specialist inserts several different procedures rather than grouping them all under a single procedure code. This amounts to an unbundling error if these multiple procedures are all related to a single major procedure. For instance, in case of a hysterectomy surgery the physician conducts a preoperative examination and a postoperative examination. In such a case, the claim should bundle these three procedures rather than presenting them separately.