Common Medical Coding Errors and How to Avoid Them

Medical coding is considered one of the crucial ways to make any healthcare system powerful. It helps medical facilities to function smoothly without any barriers or unchallenging phases. They offer assistance to both hospitals and physicians to submit appropriate coding and documentation. We have highlighted some of the mistakes that can occur and the solutions that can be implemented to offer optimized medical billing services. 

• Incorrect information about operative reports

Usually, medical coders do not initiate billing for specific procedures once they are confirmed with the physician team. Even if the procedure is listed in the performed list, then also they hesitate to bill it without proper information about operative reports. This issue can be addressed in two ways:  the provider has to make sure to write down the specific operative description required, and another way, a skilled coder should be able to circulate an operative report accurately and offer correct coding.

• The coder is unaware of bilateral procedures and services

The medical coder is away from the provider and is only conversational with the help of a phone. The same goes for the patient also as the coder is also away from the patient and is not directly connected with him. If in a case that doctor missed writing bilateral procedures or services like injections, medications, X-rays, and others, the biller will not be able to code in such cases.  The provider must understand that they are a very crucial part of the coding process. The bilaterals must be marked in the report so that medical billing services are not hampered.

• Unbundling

This can be understood as segregating procedures of each separately when there is a code already. Apart from being unethical, unbundling is illegal and it will lead to an audit in the end.  Your coders have to be aware of their comprehensive codes.

• Code as per not to the highest specificity

Some codes such as ICD-9-CM require a fourth or fifth digit to touch their highest specificity.  The claim will be rejected for sure if they are incomplete.  If a coder is not sure whether a diagnosis has to be coded to its highest level of specificity, they can confirm it with the code book or on the internet.

• Use of wrong code due to old reference material

The codes can be changed or revised at any time and the staff should keep themselves up-to-date with those changes.  Arranging and sending coders to conclaves and seminars, as well as running internal check-ups and investing in sufficient supporting material for the staff, can prevent harm to revenue that can be lost due to coding errors.