Modern Australian
The Times Real Estate

.

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

Why Gym Classes in Wollongong Are Perfect for Fitness Enthusiasts

Wollongong gym programmes offer a variety of training options catered to different ages, fitness levels and individual objectives. To support your health these sessions incorporate Zumba, yoga, Pilates, strength training and intense interval...

Top 10 Benefits of Practicing Taekwondo for All Ages

Taekwondo is more than just a martial art; it’s a way of life that offers profound physical, mental, and emotional benefits. Whether you're a child, adult, or senior, taekwondo can...

The Ultimate Guide to Daily Dental Hygiene: Tips for a Healthy Smile

Maintaining good oral hygiene is essential for a healthy smile that lasts a lifetime. While regular visits to your dentist are important, establishing an effective daily dental care routine is...

Sugar-Free Chocolate Treats: A Guilt-Free Indulgence

People are very conscious about their health and sugar-free chocolates are becoming a popular option. This is a delicious and very satisfying option. You're not sacrificing any indulgence. If you...

Importance of Gym Cleaning for Customer Satisfaction and Loyalty

A clean gym is essential for building customer satisfaction and loyalty. Members are more likely to return to a fresh and hygienic space.  Maintaining spotless equipment, floors, and common areas shows...

Exploring the Different Types of Physiotherapy: Musculoskeletal, Neurological, Cardiovascular, and Respiratory

Physiotherapy is a dynamic field that plays a pivotal role in the maintenance and restoration of physical function and wellness. It offers diverse specialties that cater to the various systems...

Beer Label Design for New Breweries: Where to Start in 2025

Imagine a customer picking up your beer based purely on its striking label. In a crowded market full of craft brews and new brands, first impression...

Functional and Fashionable: The Rise of Ladies Workwear in Australia

A perfect change in the Australian workforce has been happening in recent days. Women are contributing a lot in the male-dominated workplaces. They ...

Concrete Trailer Pump for Sale: Your Ultimate Solution for Efficient Concrete Placement

In construction projects where efficiency, precision, and flexibility are paramount, concrete trailer pumps for sale stand out as an essential piece...

Exploring Different Types of Solar Panels: Monocrystalline, Polycrystalline, and Thin-Film

The demand for solar energy continues to grow as more Australians embrace sustainable energy solutions. A crucial step in transitioning to solar pow...

Common Mistakes in Food and Wine Pairing (And How to Avoid Them)

Pairing food and wine is often considered an art, but it doesn’t have to be intimidating. The right pairing can elevate a dining experience, while...

Wine Tasting 101: A Beginner’s Guide to Smelling, Swirling, and Sipping

Wine tasting is an art form that can seem daunting to beginners, but with a little knowledge and a lot of enthusiasm, anyone can master the basics. ...

How to Fix a Clogged Shower Drain: Tips for Homeowners

A clogged shower drain is a common household issue that can be both frustrating and inconvenient. Over time, hair, soap scum, and other debris can a...

Top Trends in Electric Recliner Sofas for 2024

Electric recliner sofas have taken center level in the world of furniture layout, combining consolation, comfort, and superior generation. As we pas...

Setting Up the Perfect Home Studio for Drummers

Creating the perfect home studio for drumming is a fulfilling project that goes beyond just having a space to practice. A well-designed studio can a...

Essential Guide to Surveying Services for Land and Construction

Surveying is indispensable in all land development, real estate transactions, and construction. The core of surveys, including metric geodetic and pre...

A Step in the Right Direction: Choosing the Best Nursing Shoes and Socks for Australian Healthcare Workers

Australian healthcare professionals need to work long hours for the people. They have to be on their feet in demanding situations. So, it will be ne...

Understanding Modern Art Movements – Surrealism, Cubism, and Beyond

Modern art movements have always challenged conventions, pushing the boundaries of creativity and expression. From the fragmented perspectives of Cu...

10 Classic Dumpling Recipes to Try at Home

Dumplings are a universal delight, found in cuisines across the globe. From delicate folds to rich fillings, these versatile creations bring people ...

10 Essential Strategies for Effective Branded Advertising Campaigns

In the fast-paced world of marketing, creating an impactful branded advertising campaign is key to standing out and forging meaningful connections w...

The Evolution of Real Estate Software – From Basic Tools to Advanced AI

The real estate industry has undergone a seismic shift over the past few decades, with technological advancements playing a pivotal role in transfor...

What is RPL in Australia?

RPL is Recognised Prior Learning and refers to skills you already have that can be credited for further study or learning. For example, previous c...

Why 1/4 Zip Jumper Is Trending

The 1/4 zip jumper becomes the new status symbol. Yes, people like them. So, they are in demand nowadays. These jumpers are simple garments with a z...

The Complete Guide to Downsizing Your Home

Making the decision to downsize your home is a significant life change that can feel overwhelming at first. Whether you're empty nesters looking to si...