Modern Australian
Men's Weekly

.

Coding Mistakes that Trigger Medical Claims Audits (and How to Avoid Them)


If there's one thing that keeps healthcare administrators and physicians up at night, it's the thought of facing a medical claims audit. While audits serve an important purpose in detecting fraudulent or erroneous billing practices, they can severely impact provider revenue and disrupt workflow. Many audits are triggered by preventable coding mistakes.

By sharpening coding knowledge, updating policies, and adding extra layers of auditing, providers can minimize errors and hopefully, interactions with auditors. This article outlines some common CPT, HCPCS Level II, and ICD-10 coding mistakes and how your practice can tighten up its workflow. 

Unbundling Coding Errors

One of the biggest coding mistakes that invites unwanted scrutiny during a medical claim audit is unbundling services. Unbundling involves reporting each component of a procedure as if it was performed independently, instead of using an all-inclusive code. Not only is this perceived as upcoding, but it is considered fraudulent.

Carefully review bundled service codes - identified with parenthetical statements in code text or symbols. Ensure coders understand how to appropriately use bundled codes per payer guidelines. Implement nag screens in chargemaster systems that alert the coder if an unbundled code is used when a bundled option exists.

Incomplete Diagnosis Codes

Similarly, diagnosis codes must precisely capture a patient's conditions as addressed during the encounter and documented on the record. Omitting relevant secondary diagnoses leads to incomplete codes. This causes the perception that the level of complexity has been manipulated to justify higher reimbursement.

Have physicians provide coders with a comprehensive diagnosis list, while coders review charts thoroughly. Encourage coders to follow up for clarification when documentation lacks specificity. Conduct internal audits periodically to catch incomplete diagnosis codes. 

Incorrect Procedure Code Modifiers

Certain billing scenarios require procedure code modifiers to convey additional details. Modifiers explain special circumstances, the site of service, or professional and technical components. Applying the wrong modifier or omitting modifiers can have serious ramifications. 

For example, modifier -25 signifies that a separately identifiable E/M service was also rendered. Excluding this can signal that a service was wrongly upcoded. Have coders maintain an internal modifiers cheat sheet, double check selections, and seek physician input if unsure when modifiers should apply.

Staying Out of the Spotlight

A priority for providers large and small is flying under the radar when it comes to coding errors. By pinpointing problem areas through self-audits, analyzing coder productivity metrics, and requests for clarification, you can intercede before mistakes reach auditors’ desks. Hold regular training refreshers that address frequent errors and issues identified through self-monitoring.

When issues crop up, be proactive. Determine whether individual staff training is needed or whether company-wide protocols must improve. Develop an open line of communication between coders and physicians to address problems in real time. Stay vigilant, while being mindful of coder morale, as facilities with high turnover tend to have lower quality standards.

Implementing tighter protocols, self-auditing regularly, and supporting staff through training can help minimize the coding errors that capture auditors’ attention. Stay up to date on all coding and documentation guidelines to keep your practice running smoothly.

Health Features

Your Guide to Finding the Right GP: What Perth City Doctors Offer Today

Choosing a General Practitioner (GP) is one of the most important health decisions you’ll make. Luckily, Perth’s vibrant CBD now hosts a new generation of clinics that combine traditional bedside manner...

The Comprehensive Guide to Physiotherapy: Benefits & Techniques

It employs hands-on care, movement and advice to aid recovery and prevent further issues. Individuals of all stages of life utilize physiotherapy for pain, muscular strength, balance, or joint concerns...

What Can Be Funded by the NDIS? A Guide to Approved Supports

The National Disability Insurance Scheme (NDIS) is designed to empower Australians with disability by providing funding for supports that improve independence, social participation, and overall quality of life. However, navigating...

What Causes Depression? Biological, Psychological, and Social Triggers Explained

Depression is a complex mental health condition that can impact every aspect of a person’s life—from sleep and energy levels to relationships and sense of self-worth. It’s more than just...

How to Choose the Right First Aid Kit for Your Workplace

Ever walked past your workplace first aid kit and wondered if that dusty box actually contains what you'd need in a real emergency? We know that feeling!  Most Australian business owners...

From White Belt To Warrior: How To Train Your Body For BJJ Endurance

Brazilian Jiu-Jitsu (BJJ) is as much a mental chess match as it is a physical grind. Whether you’re new to the mats or prepping for high-level competition, developing endurance is...

Refurbished iPads Are Better Than New Ones (Here's Why)

Image by rawpixel.com on Freepik Apple's refurbished iPad program has quietly become one of the best deals in tech. While everyone obsesses over the ...

Your Guide to Finding the Right GP: What Perth City Doctors Offer Today

Choosing a General Practitioner (GP) is one of the most important health decisions you’ll make. Luckily, Perth’s vibrant CBD now hosts a new ge...

Why Every Mining Operation Needs a Robust Safety Management System

Mining is one of the backbones of the Australian economy, particularly in Western Australia. Back in 2019-20, mining contributed 10.4% of Australiaâ...

Australian Classic Literature Enjoys Resurgence

Welcome back to the good old days of storytelling! As the modern world becomes increasingly more demanding, returning to childhood favourites offers...

Building a Governance Model for Headless Content Management at Scale

Image by pch.vector on Freepik There's never been a better time to implement a headless content management system (CMS) to gain the flexibility and ...

Understanding Trade Insurance: Essential Protection for Businesses

Image by Drazen Zigic on Freepik In the current economic environment, trade insurance is an important element for companies trading both locally an...

Choosing the Right Timber for External Cladding

Timber cladding is one of those finishes that pulls double duty: it makes a building look warm and welcoming, and it quietly shields the frame from ...

Top Services Offered by Diesel Mechanics in Brisbane

Keeping a diesel vehicle running at its best takes more than the occasional oil change. When you invest in regular specialist care, you protect the ...

Top 5 Benefits of Hiring Professional House Removalists

Moving day should feel like the start of a new adventure, not the end of your patience. Yet once the settlement papers are signed and the champagne ...

Navigating the Digital Landscape: Managed IT Solutions and IT Services in Townsville

As technology advances at an unprecedented pace, companies must adapt to embrace the transformation ahead. With an evolving technology landscape, mana...

Types of Catering You Should Consider for Your Next Event

Choosing the right type of catering service can elevate your event from ordinary to unforgettable. Whether it’s an elegant wedding, corporate func...

Understanding the Benefits of Split System Installation for Your Home

Climate control is essential to maintaining comfort in your home, especially during the extreme temperatures that many regions face. Whether you’r...

Best Aluminium Window Sliding Designs for Natural Light and Airflow

Bringing natural light and airflow into a space is one of the most efficient ways to create a healthy and comfortable home. In Sydney and across Aus...

Maximising Operational Efficiency: Electric Winch Hire Australia and Hydraulic Power Pack Hire Solutions

Image by jcomp on Freepik From urban construction sites and remote mining operations to coastal maritime facilities, specialised equipment solutio...

Navigating the System: Your Guide to Support Finding Work with a Disability Around Melbourne

Image by freepik Finding the right job can be a challenge for anyone, but it can feel particularly daunting when you're also navigating life with a ...

Say Goodbye to Draughts and Hello to Savings: Your Guide to Perth Window Replacement

Image by prostooleh on Freepik Are your windows looking worse for wear? Are you paying a hefty power bill due to sneaky draughts and poor insulation...

How to Choose the Right Horse Trailer for Your Riding Needs

Many horse owners travel long distances for riding lessons, competitions, or to move horses between properties. Having a safe and reliable trailer i...

Sydney Turf Installer for Instant Green Lawns and Long-Term Performance

Having a green lawn at home makes everything look better. Whether it’s the front yard, backyard, or a small patch beside the driveway, people in S...