The integrity of the request for payment rests on the accuracy and honesty of the coding and billing within a practice. Incorrect work could simply be an error, or it could represent a deliberate effort to obtain fraudulent payment. Medical billers and coders are responsible for ensuring that these errors are limited and promptly fixed. Among the most common causes of errors in coding and billing are truncated coding, up-coding or down-coding, and using an inappropriate modifier or no modifier when one is required.
Truncated coding is when a medical coder uses diagnosis codes that are not as specific as possible. Diagnoses and procedures must be correctly linked on health care claims because payers analyze this connection to determine the medical necessity of the charges. If it is not properly coded the payer could deny the payment of the service.
Another common error is the act of “up-coding” or “down-coding.” Up-coding is using a procedure code that provides a higher reimbursement rate than the correct code. Down-coding is when a medical biller uses a lower level code. Some physicians’ may down-code, just to be on the safe side, especially with E/M codes.
Incorrect use of modifiers is another major error that affects the billing procedure. CPT modifiers can eliminate the impression of duplicate billing or unbundling. For example, when a procedure is performed, the patient’s condition may require the physician to perform an evaluation and management (E/M) service above and beyond the usual pre- and postoperative care associated with that procedure. In this case, a modifier of -25 should be used. This modifier says that this was clearly a separate E/M service by the same physician on the same day of service.
Improper coding that can lead to incorrect payment for Medicare claims is controlled by the Medicare National Correct Coding Initiative (CCI) edits that are designed to reject claims that do not...