MEDICAL BILLING & CODING –

Working as a medical biller and coder is a challenging and rewarding job that takes you into the heart of the medical industry. To succeed, you’ll need to know how to file an error-free claim, important acronyms, what to expect as the U.S. prepares for ICD-10, and what to look for in a payer contract.

MEDICAL BILLING: FILING A CLEAN, ERROR-FREE CLAIM

A clean medical claim is one that has no mistakes and can be processed without additional information from the provider or a third party. It’s correct from top to bottom. A clean medical claim meets the following criteria:

The healthcare provider is licensed to practice on the date of service and is not under inves

tigation for fraud.

Every procedure code has a supporting diagnosis code, which eliminates any questions about medical necessity. In addition, the form includes no expired or deleted codes.

The patient’s coverage was in effect on the date of service, and the patient’s insurance covers the service provided.

The claim form includes all the required information (patient name, address, date of birth, identification number, and group number) in the correct fields.

The form correctly identifies the payer and includes the right payer identification number and payer mailing address.

The claim is submitted on time.

 

POTENTIAL BILLING PROBLEMS AND RETURNED CLAIMS

The goal of the medical biller is to ensure that the provider is properly reimbursed for their services. In the pursuit of this goal, errors, both human and electronic, are unfortunately unavoidable. Since the process of medical billing involves two incredibly important elements (namely, health and money), it’s important to reduce as many of these errors as possible. In this brief course, we’ll introduce you to some common errors in the medical billing practice.

Before we jump into that discussion, however, let’s review the difference between a rejected and denied claim.

DENIED AND REJECTED CLAIMS

As you’ll recall from previous Courses, a rejected claim is not the same as a denied one. A rejected claim is one that contains one or many errors found before the claim is processed. These errors prevent the insurance company from paying the bill as it is composed, and the rejected claim is returned to the biller in order to be corrected. A rejected claim may be the result of a clerical error, or it may come down to mismatched procedure and ICD codes. A rejected claim will be returned to the biller with an explanation of the error. These claims are then corrected and resubmitted.

Clearinghouses employ a process called “scrubbing” in order to avoid rejected claims. The end goal, for billers and clearinghouses, is a “clean” claim.

Denied claims, on the other hand, are claims that the payer has processed and deemed unpayable. These claims may violate the terms of the payer-patient contract, or they may just contain some sort of vital error that was only caught after processing. Payers will include an explanation for why a claim is denied when they send the denied claim back to the biller. Many times, these claims can be appealed and sent back to the payer for processing, but this process can be time-consuming and, therefore, costly. For that reason, it’s important to try and get as many claims “clean” on the first go, and not waste any time billing for procedures that are incompatible with a patient’s coverage.

 

SIMPLE ERRORS

Now that we’ve reviewed denied and rejected claims, let’s look at some of the basic errors that can get a claim returned to the biller.

• INCORRECT PATIENT INFORMATION

  Sex, name, DOB, insurance ID number, etc.

• INCORRECT PROVIDER INFORMATION

  Address, name, contact information, etc.

• INCORRECT INSURANCE PROVIDER INFORMATION

  Wrong policy number, address, etc

• INCORRECT CODES

  Entering confusing ICD, CPT, or HPCS codes; entering confusing Place of Service codes; attaching conflicting or confusing modifiers to HCPCS or CPT codes; entering too few or too many digits to an ICD, CPT, or HCPCS codes

• MISMATCHED MEDICAL CODES

  Entering confusing ICD codes with CPT codes, or vice versa, etc

• LEAVING OUT CODES ALTOGETHER FOR PROCEDURES OR DIAGNOSES
• DUPLICATE BILLING

  This occurs when someone at the provider’s office submits a claim for a procedure without checking whether that service has been paid for/reported. Duplicate billing can create a huge headache for billers and payers alike, because it may appear that a patient received two identical x-rays on one day, which would effectively double the amount sent to the payer.

• UNDERCODING

  Undercoding occurs when a provider intentionally leaves out a procedure code from a superbill, or codes for a less serious or extensive procedure than the patient received. Undercoding may be done to avoid audits for certain procedures, or to try and save money for the patient. This process is illegal, and counts as a type of fraud.

• UPCODING

  Like undercoding, this is a fraudulent process wherein the provider intentionally misrepresents the work they performed on a patient. In upcoding, a practice enters codes for services a patient did not receive, or codes for more intensive procedures then the provider actually performed. Upcoding is typically done in an attempt to receive more money from a payer. This, like undercoding, is a fraudulent practice, and should be noted and reported immediately.

• POOR DOCUMENTATION

  While not a fraudulent practice like upcoding or undercoding, poor documentation can also negatively affect the claims process. If a provider has provided incorrect, illegible, or incomplete documentation of a procedure or patient visit, it’s difficult to make an accurate or complete claim. In cases of sloppy documentation, the biller should contact the provider and ask for more information.

• NO EOB ON DENIED CLAIM

  In certain cases, the payer may fail to attach the Explanation of Benefits (EOB) to a denied claim. In cases like this, it’s difficult to note the error on a denied claim, which slows down the (already slow) appeals process.

READING PAYER CONTRACTS FOR KEY MEDICAL BILLING AND CODING DETAILS

Insurance companies (payers) offer various levels of coverage to their members, and as the medical biller/coder, you must be able to navigate payer contracts to gather the information you need to prepare and follow-up on claims. Many payers or networks have standardized contracts that they offer to healthcare providers. A well-defined contract does the following:

Defines the number of days after the encounter that the provider has to submit the claim. This is called timely filing.

Specifies how many days after receipt of the claim the payer has to make payment.

Specifies which of the payer plans are included, the frequency of services that it will cover (for certain procedures), and the type of claim that providers must submit.

Identifies special circumstances, such as how unlisted procedures will be reimbursed, which procedures are carved out of the fee schedule, the number of procedures that the payer will pay per encounter, and how to apply the multiple procedure discount.

Identifies the appeals process.

Identifies cost-intensive supplies or procedures (such as implants, screws, anchors, plates, rods, and so on) that may need to be paid.

As a biller/coder, make sure you’re familiar with the contract specifics, and if you have any questions, talk to more experienced billers and coders in your office or call the payer directly for clarification.

Source: Medical Billing and Coding For Dummies, 2nd Edition By Karen Smiley