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Stop Losing Revenue: 6 Medical Coding Mistakes to Avoid

Posted by Kristia Smith on Feb 13, 2019 12:41:08 PM

medical practice revenue system

Medical coding is one of the most critical components of any medical practice. Accuracy in this area is very important because it might affect patient safety, clinic operations and also your practice’s revenue. So, how can improper medical coding affect your medical practice? That’s a good question that many practices need to start asking.

We’ll get to the answer - but first, let’s examine what exactly medical coding is and why it is so important.


What is medical coding?

Many of you are likely already more familiar with medical coding way than you would probably like to be! But as a refresher, medical coding is a system of codes that serve as unique labels for a patient’s diagnosis, symptom, or cause of death. Two common medical coding classification systems that are prominent in today’s healthcare industry are the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT).

medical coding benefitsUsed by more than 100 countries, ICD is the standard international system of classifying mortality and morbidity statistics. This system is used by healthcare facilities to define diseases and allocate resources to provide care. On the other hand, CPT is a medical code set that is used to report medical, surgical, diagnostic and radiology procedures and services to entities such as physicians, health insurance companies and accreditation organizations.

Medical coders take information about diagnoses, treatments, procedures, and medications then translate them into alphanumeric codes. The information comes from different sources including transcriptions, medical notes, electronic records, and lab results. The information might also come from urinalysis, pathology results, or radiology assessments.

A good number of cases are simple to code. However, there are also cases where thorough research is needed in order to assign the proper code. And, sometimes, even the most commonly used codes have significant gray areas that are open for meticulous examination among medical codes. And if there are unusual or difficult cases to figure out, coding guidelines may be confusing to interpret. However, with the help of other coding experts, whether seeking advice in online forums or reaching out to a medical coding company for support, healthcare providers can better understand the cases and determine the right codes.


Why is medical coding important?

Medical coding is an integral part of medical billing and plays an important role when it comes to submitting medical claims to insurers. Coding claims accurately inform the insurance payer of a patient’s injury or illness and also the treatment method, which allows insurance companies to determine whether the payments for certain procedures should be reimbursed, reduced or denied. Using the wrong medical codes can result to claims being denied. When this happens, your medical practice will very likely lose money because you will not be fully paid on the services you provided. And that is why it is highly critical that medical practices have a knowledgeable team of coders so that no medical coding errors are made.


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What are the common medical coding mistakes?

Medical coding can be complicated and an excessive amount of work. That’s why it requires skilled professionals who can read, record, and quickly interpret complex medical information. As mentioned earlier, proper medical coding is important, especially in insurance reimbursements. This is the reason why medical coding professionals should be diligent and detail oriented, because one mistake can cause your practice to lose revenue.


Here are 6 medical coding mistakes to avoid:


Medical upcoding is a form of healthcare fraud that involves the manipulation of CPT codes. Essentially, it is the practice of billing for more costly and extensive service than a healthcare provider actually performed. For instance, a healthcare provider may use a code for a more expensive procedure, when actually, a less expensive procedure was performed. Or, to receive a higher reimbursement rate, a healthcare provider may indicate that a patient has a diagnosis that is more serious than they actually do. If a healthcare provider engages in this fraudulent act, the provider is lying by using a false CPT to receive a higher reimbursement amount.

Upcoding is a serious compliance risk that may lead to administrators being fired, reimbursement take backs, payer audits, fraudulent billing charges, or even jail time. There are many healthcare providers that have been caught engaging in upcoding. Make sure that your name doesn’t get added to that list.



medical billing and revenueUndercoding happens when the codes billed do not represent the full scope of the work performed by the physician or facility - this results to a loss of revenue. Some healthcare providers intentionally undercode to prevent themselves from being under the scrutiny of insurance companies. Many providers just don’t want to trigger an unnecessary audit. Typically, undercoding is done out of fear of being audited however, in many cases, higher codes are justified based on the documentation that the clinics provide.

Most practices do not want to undergo an audit, so most healthcare providers avoid this by avoiding overcoding at all costs. However, it is important to note that by doing so, medical practices also lose a lot of money.


Use of Inappropriate Modifier

One of the common reasons medical claims get denied is because healthcare providers use invalid or inappropriate modifier combinations. These modifiers consist of a two digit number, two letters or alphanumeric characters. Modifiers mean that additional work was required, that procedures were performed by multiple providers, or that unusual tasks occurred when servicing the patient. By simply using the proper modifiers, denied claims can be prevented.


Mismatched Codes

It is important that diagnostics and treatment codes match. It is necessary for healthcare providers to complement the ICD codes to CPT codes. The mismatch can be bad especially when an upcode is involved. If the provider fails to match the diagnosis and treatment codes, it would be difficult to make an accurate or complete claim. Furthermore, mismatched coding of the specifics during diagnosis could result in improper patient care.


Incorrect Injections Billing

It is important that the healthcare provider only report some code for the entire session during which the injections take place. By reporting multiple units of a code, a provider is practically asking for their submission to be denied.


Use of Unlisted or Incorrect Codes

With thousands of CPT codes, it is easy to possibly select the wrong code especially if you’re not an experienced coder. There are some procedures or services that do not have a code assigned to it. The healthcare provider can still bill for such procedure or treatment. However, if they use an unlisted code to properly bill a service, the correct and complete documentation must also be made.

Additionally, sometimes providers just simply overlook the basics; the most basic errors can also get a claim returned. A few basic billing errors that providers sometimes make include providing incorrect patient information (name, DOB and insurance number) and incorrect insurance provider information (address or policy number).


The Bottom Line

These are just some of the mistakes that healthcare provider should avoid to ensure that all claims will be reimbursable by health insurances. Medical staff should be thorough, accurate, and detail-oriented so that they avoid these mistakes. And honestly, simply staying up-to-date on coding rules and initiatives will help your practice prevent a lot of coding errors! However, it is understandable that your medical staff has other responsibilities. It might be difficult for them to keep up with coding changes. Therefore, outsourcing is a great medical solution that many practices nationwide choose.

Medical coding can be a lot of work, and minor errors can cause major harm. That is why the option to outsource is so attractive. If your practice chooses to outsource its medical billing and coding, your billing cycles will run smoother, you will experience less rejections, and you will worry less about coding mistakes. DrCatalyst is a leading medical services company, and we have a team of experienced medical billers who can help your practice reduce coding errors and increase your revenue. To learn more about our medical coding services, feel free to contact us.

Topics: Medical Coding

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