The impact of accurate coding
Accurate coding is an integral part of efficient claims submission. Incorrect coding can be construed as fraud or abuse. This can have a negative effect on any healthcare organization. If the wrong diagnostic or procedural codes are used, the claim can be denied and will have to be resubmitted. If coding is done incorrectly, the claim can be rejected as not medically necessary. Let’s take a closer look at how to prevent fraud and abuse and the rejection of claims.
Preventing fraud and abuse
In any healthcare environment, accurate coding is essential to prevent fraud and abuse in reimbursement.
Violations of the laws governing reimbursement may have the following results:
- Nonpayment of claims
- Civil monetary penalties (CMPs)
- Exclusion from the payer program
- Criminal and civil liability
- In extreme cases, jail time
These laws may be changed or updated. The person who is responsible for coding must pay close attention to detail and act as a sort of medical detective to prevent a case against a provider or clinic. The ICD-10-CM and CPT/HCPCS manuals are updated annually. New coding manuals have a few pages dedicated to the updates for that particular year. Accurate use of ICD-10-CM and CPT/HCPCS manuals is essential for the correct translation of the claim information in the health record into the correct codes. However, as models of providing healthcare change, they can present some challenges for accurate coding and billing procedures.
Guidelines for reviewing claims before submission
The following guidelines can help ensure that clean insurance claims are submitted.
General review steps
- Proofread the form or data entered into the electronic system carefully for accuracy and completeness.
- Make certain any necessary attachments are included with the completed form.
- Follow office policies and guidelines for claim review and signatures.
- Forward the original claim to the proper insurance carrier either by mail or electronically.
- Make sure the patient’s and/or insured’s name, address, ID, group, and/or policy number are identical to the information printed on the insurance card.
- Make sure the patient’s birth date and gender are the same as in the medical record.
Field-specific checks
- Block 12: Make sure the patient has authorized the release of information and that Block 12 has a handwritten signature, the words “Signature on File,” or the acronym SOF. Block 13 (the patient’s authorization to pay benefits to the provider) and Block 31 (the provider’s signature) may also show “Signature on File” or SOF.
- Make sure the diagnosis is not missing or incomplete.
- Check that the diagnosis has been coded accurately, according to the ICD-10-CM coding manual and is linked to the treatment.
- List the fees for each charge individually; or, if more than 1 day or unit is entered in Block 24G, the fees must be computed correctly.
- Block 27 (Accept Assignment?): Put an X in the YES box if the provider is a PAR provider or has an agreement with the insurance company to accept assignment.
- Block 24J and Block 33a: Make sure the provider’s NPI, corresponding to the insurance carrier being billed, has been entered in Block 24J and again in Block 33a.
Preventing rejection of a claim
It is important for the medical assistant to understand and comply with the specific guidelines for completing a CMS-1500 established by each insurance company. This prevents delays in reimbursement and denial of payment. The guidelines for Medicare, Medicaid, TRICARE, and workers’ compensation can be found online at the websites of these healthcare insurers. Most practice management billing systems have built-in claim scrubbers that catch dirty claims before a clearinghouse transmits them to the insurance company.
Communication with providers about third-party requirements
Providers rely on their medical office staff to stay current on the frequent changes made by government plans, private insurers, and coding updates - changes that can leave an outdated encounter form/superbill listing codes that no longer exist or omitting newer services. When this happens, tactfully discuss updating the form with the provider; if they’re reluctant to replace it, updating just the codes on it (or adding an open text box for occasional procedures) is a reasonable compromise. Approach these conversations patiently and respectfully, since the pace of change in coding and billing can be overwhelming for providers focused on patient care.
Claims tracking
Claims can become lost in either the healthcare organization’s system or the insurance company’s system, so it’s important to track every submitted claim to ensure timely reimbursement. Some claims are rejected - meaning they never entered the payer’s adjudication process because of errors or missing data - while others are denied, meaning they were adjudicated but the payer refused payment. Reviewing the EOB/RA shows which happened and why.
Clearinghouses send a confirmation report after submission of a claim. The medical biller should always confirm that the claims submitted to the clearinghouse match the claims listed on the confirmation report. If direct billing is used, the medical biller must set up a system to track the claims that were submitted. Medical assistants should maintain this practice to ensure every claim is submitted correctly.
The claim submission confirmation report also indicates claims that were rejected because they were incomplete. These claims should be corrected and resubmitted electronically immediately. Often these claims are rejected for data entry errors. The medical biller should compare the patient’s information in the practice management software to the information on the patient’s registration form and scanned insurance card to ensure accuracy.
It typically takes 10 to 14 business days for insurance companies to process insurance claims electronically. If the insurance company has not responded after 30 days, the medical biller should inquire about the status of the claim. This can be done through the company’s provider web portal or by calling the provider services number on the back of the patient’s insurance ID card. To verify the claim status, you must provide the following information:
- Insured subscriber’s member number and birth date
- Patient’s name and birth date
- Date of service
With this information, the insurance company should be able to tell if the claim has been paid, is still in process, was denied, or was never received. The medical biller will use this information for the proper follow-up. This could involve a number of actions:
- Investigating the records at the clinic to see if the payment came in but was applied to the incorrect patient account.
- Researching the denial and re-submitting the claim.
- Determining why the claim was not received and resubmitting it.
The state insurance commission has standards that insurance companies must abide by, including claim processing times and payment guidelines. Medical assistants should keep the commission’s contact information in the office medical billing manual as a reference in case a claim should be reported.