Billing DOs and DONTs: Easy Mistakes to Avoid

Billing DOs and DONTs

Documentation of a patient’s condition must be 100% accurate. Accuracy, as we should all know, hinges in large part on entering the right diagnosis code—down to the last number (this is a reminder to those of you who insist on entering abbreviated codes…).

ICD-9 codes, mostly unchanged for years, always required at least three numbers, sometimes four or five. Along with collective anxiety from the entire medical world, ICD-10 brought with it a boatload of new codes, many as long as seven alpha-numeric characters.

Confusion surrounding coding practices has always been an issue. Numerous changes are made each year, from code revisions, to overall coding guidelines. It can be difficult for practices to stay on top of it all. Bad habits form which can have consequences for their reputations, and bottom lines. Today, we will discuss two particular habits that have been on the rise of late.

Upcoding and Downcoding

If a plumber sent someone an invoice for services he didn’t perform, or for services more complicated than what was called for (replacing whole lengths of pipe, for instance, instead of dealing with a simple drain clog), that person would be a little upset. On the other hand, what if that same person’s water heater exploded, leaving their basement flooded. How would they feel if their plumber arrived late, with nothing but a wrench and a roll of thread seal tape because his secretary gave him faulty information?

For medical professionals, errors such as these can bring consequences far worse than a negative review on Angie’s List.

Upcoding is the term for reporting and billing for a higher-level service, or a more grave diagnosis than was necessary, or originally documented. While this can be a simple case of human error, the space between “acute” and “chronic” is a wide one. What seems like a minor mistake in coding can not only cost you money, but can also lead to audits, and accusations of fraudulent billing practices.

Downcoding, then, is the opposite phenomenon. While upcoding can be blamed on too much information, downcoding results from a lack of detail in documentation. For example, a patient’s record may state that they have a certain kind of COPD, but the specificity of the condition, other ancillary conditions attached, and specific course of treatment may go underreported.

Like its counter-practice, downcoding can simply be the result of human error. However, purposeful downcoding has been a recent trend among physicians. They do this in order to avoid accusations of, and penalties attached to upcoding. This in not wise. Both upcoding and downcoding are considered types of fraud. In the case of the latter, you are denying yourself substantial revenue, while negligently putting a patient’s health at risk.

If you are concerned about the accuracy and consistency of your billing practices, or how your documentation history may look to outside agencies, the right response should be to perform your own audits internally. If done once or twice a year, you will be able to spot revenue gaps, inconsistencies, and whether or not your staff must be retrained on coding specifics.

Chronic Care billing

As of this past year, practices can finally be compensated for the amount of time they spend amending, and coordinating the treatment plans of chronically ill patients. This can be a boon to primary care physicians. First, however, you must make sure that the proper criteria are met before entering that code for chronic care management services (which, in case you forgot, is 99490).

The operating number is twenty (20). That is to say, there must be at least 20 documented minutes per month, wherein a care plan is created, executed, revised, and closely watched. There must be multiple chronic conditions (two is a crowd, in this case), expected to last at least a year, which put said patients at risk of death, or severe physical decline.

Another recent trend among primary care physicians has been to forgo the chronic care management fee altogether. Why is this? The same reasons physicians dread billing and coding altogether: exorbitant documentation time, and the high margin for error. Then there is the prospect of having to convince skeptical patients that the co-pay is worth it.

If you’ve heeded our past advice about hiring crack coding and billing specialists, LPNs and PAs with leadership and administrative capabilities, and adopting a team-based approach to administering care, then you’re almost there. Next comes investing time and money in your practice’s technology. Your EHR must be set up to seamlessly record the kind of documentation required, and be accessible to all staff members involved with the CCM plan. Your plan must also be accessible to other providers involved in the patient’s care.

Yes, medical coding is difficult, and many of us are still actively trying to wrap our heads around ICD-10 standards. But cutting corners here cuts profit, accountability, and patient trust. Resist the temptation to rush. Make sure you and your staff are trained on up-to-date billing and coding practices. Schedule a time in the next few months for some “housekeeping” to ensure that your billing practices have been up to par.


Brian Torchin

| HCRC Staffing | |