- Wrong interpretation of operative reports – Often coders do not bill for a particular procedure unless they see it specifically documented by the doctor. Even if the description of the procedure is listed in the procedures performed, coders are hesitant to code it without the actual operative description. This problem can be helped in two ways: the provider can make sure to write down the specific operative description needed, and second, an experienced coder should be able to interpret an operative report properly and provide correct coding.
- The coder does not know about the bilateral procedure/services – Often the medical coder is at a second location, in an office away from the provider and the patients. If the doctor forgets to write bilateral procedure or service such as injections, medications, X-rays, and so forth, the biller will have no way to code for them. The provider must remember that he or she is a very important part of the coding process and that the bilaterals must be circled in the report to result in proper medical billing services.
- Unbundling – This means separating into pieces a procedure and charging for each part separately when there is already a comprehensive code. Besides being unethical, unbundling is illegal and it will attract an audit. Have your coders know their comprehensive codes well.
- Code not to its highest specificity – Some ICD-9-CM codes need a fourth or fifth digit to get to their highest specificity. If incomplete, the claim will be rejected. If a coder is unsure whether a diagnosis is coded to its highest level of specificity he or she can look it up in the code book or on the internet.
Wrong codes used due to outdated reference material – The codes change and the staff needs to be up-to-date with those changes. Sending coders to seminars or having them attend web-seminars, as well as running internal check-ups and purchasing sufficient supporting material for the staff, can prevent lost or delayed revenue that can be lost due to coding errors.
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