ICD-10-CM and CPT® Coding Mistakes Can Cost You – And not Just Financially

Medical coding errors fall into the broad categories of “fraud” and “abuse.” 

Medical practices are concentrating on critical practice changes in 2020 and 2021, but it is important not to lose focus on the basics of correct coding. Don’t be guilty of common CPT and ICD-10-CM coding errors, as it can not only cost your practice millions of dollars in lost revenue, but cause compliance issues that could tag your practice for an audit. Here are some common errors that can lead to practice headaches and loss of revenue down the road.

1. Randomly using modifiers. Modifiers are the two-digit codes added to a service or procedure that tells the payor of special circumstances. The American Medical Association (AMA) develops CPT modifiers, which are numeric, and the Centers for Medicare & Medicaid Services (CMS) develops HCPCS modifiers, which are alphanumeric or alphabetic. Both types of modifiers can be used on CPT or HCPCS codes. Why would someone randomly apply a modifier? Misunderstanding, incorrect information, or a desire to get a claim paid, just to mention a few examples. But for both compliance and revenue reasons, correct use of modifiers is critical. Using modifiers requires an understanding of the global surgical package and National Correct Coding Initiative (NCCI) edits. There are several good coding books on the market that exhaustively explain modifiers.
2. Selecting the wrong procedure code. With more than 75,000 CPT codes, it is easy to select an incorrect procedure code. However, the source of such an error is usually not confusion about the procedure performed. Incomplete or inaccurate code descriptions on encounter forms, cheat sheets, and electronic charge systems are significant sources of error. Failing to read the editorial comments at the start of the section in the CPT book or the notes near the code is another cause of this type of error, as is not reading specific coding companions available to assist in special circumstances.
3. Failing to link diagnosis codes. A CPT or HCPCS code tells the payor what service was performed. The diagnosis code tells the payor the reason for the service. Some patients present for more than one condition may require unrelated services. Other patients may receive a service that is only covered for a specific indication. For example, say a patient presents to a family physician for hypertension, but has a wart destroyed during the same visit. The code for the office visit must be linked to hypertension, and the code for the wart destruction must be linked to the diagnosis code for warts. Most often, only one diagnosis is listed or linked, and denials are then a given.
4. Using a nurse visit in place of another service. Some practices still believe that they can charge a nurse visit with an injection or for a venipuncture “because our nurse takes the patient’s vital signs.” Or they ask, “can we bill a nurse visit with a flu shot?” Nurse visits are bundled into injection codes, and will not be paid separately by a payor using NCCI edits, or any payor using proprietary edits. As for the venipuncture, the practice motivation is that a nurse visit pays more than a venipuncture. But it does not accurately describe the reason for the visit, or the service performed. If the reason for the visit and the service performed was venipuncture, bill venipuncture. If the patient presented for an allergy shot, bill for the administration of the allergen. Assessing the patient pre- and post-shot is part of the payment for the administration of the planned injection.
5. Not keeping up to date. Medical practices and hospitals are understandably cautious about budgets. But failing to keep up to date on new coding rules and initiatives is an expensive mistake. It results in lost revenue and potential compliance risk for practices. I see many practices pouring hundreds of thousands of dollars into electronic medical records (EMRs) and new medical diagnostics, but when I ask what their coding education budget is for the year, rarely do I hear more than $1,000 – and that’s a practice that’s ahead of the curve. As a healthcare consultant, I find myself in more practices with coders using dated code books, referencing outdated material, and not having the financial resources to bring their staff up to speed on the current rules.

When it comes to medical coding errors, they fall into the broad categories of “fraud” and “abuse.”

The former involves intentional misrepresentation. The latter means “the falsification was an innocent mistake, but nonetheless representative,” according to the AMA’s Principles of CPT® Coding, ninth edition. An example of abuse could involve coding “for a more complex service than was performed due to a misunderstanding of the coding system,” the text notes.

The AMA has a number of resources to help you accurately bill procedures and services with Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.

Here are some of the most common mix-ups to avoid in medical coding.

Unbundling codes. When there is a single code available that captures payment for the component parts of a procedure, that is what should be used. “Unbundling” refers to using multiple CPT codes for those parts of the procedure, either due to misunderstanding or in an effort to increase payment.

Upcoding. Say a physician meets for a few minutes with a patient about a routine question, but the coder bills for a full exam lasting 45 minutes, because that what was checked on the charge capture form. That is a no-no, though often, cases of upcoding are not so blatant.

But sometimes they are, and the consequences can be severe. One psychiatrist was fined $400,000 and permanently excluded from taking part in Medicare and Medicaid, in part due to upcoding. He billed for 30- or 60-minute face-to-face sessions with patients, when in reality, he was only meeting with patients for 15 minutes each to do medication checks.

Failing to check NCCI edits when reporting multiple codes. CMS developed the NCCI to help ensure that correct coding methods were followed, helping providers avoid inappropriate payments for Medicare Part B claims. These are automated prepayment edits that are “reached by analyzing every pair of codes billed for the same patient on the same service date by the same provider to see if an edit exists in the NCCI,” the AMA’s text notes. “If there is an NCCI edit, one of the codes is denied.”

Improper reporting of the infusion and hydration codes, which are time-based. Good documentation of the start and stop times are essential for medical coders to properly bill for these services. And then there are wrinkles involving services that are provided over two days of service.

Improper reporting of injection codes. Only report one code for an entire session during which the injections take place, instead of multiple units of a code. This error in coding has been a top 10 Recovery Audit Contractor (RAC) audit recoupment in the past few years.

Reporting unlisted codes without documentation. If you must use an unlisted code to properly bill for a service, you must properly document it.

Sometimes, it’s just about the money.

Choosing the correct code can make a difference of $50.

When you are attempting to distinguish nasopharyngoscopy from laryngoscopy, just remember this: what matters most is the area the ENT examines, not where the physician inserts the scope.
 
When choosing between nasopharyngoscopy (92511, Nasopharyngoscopy with endoscope [separate procedure]) and laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic), you should consider not whether the ENT introduces the scope through the mouth or the nose, as you might think. Instead, the key to proper coding is the anatomic area (nasopharynx or larynx) the ENT examines with the scope.

Sometimes, physicians choose to perform a nasal scope insertion for a laryngoscopy, because inserting the scope through the patient’s nose is easier than making the patient hold his mouth open for a long time, and because going through the nose doesn’t provoke the patient’s gag reflex. So if you read “nasal scope insertion” in your physician’s documentation and assume he or she performed a nasopharyngoscopy, you could be jumping to an incorrect conclusion.

Remember that 92511 reimburses higher than 31575 in the non-facility setting (3.32 relative value units vs. 1.91 RVUs, or about a $50 difference, on average), so choosing the correct code has significant meaning for your bottom line.

Solution: read your ENT’s documentation very thoroughly to discern what anatomic part he or she examined with the scope procedure; this fact should guide your code selection. 

Example: if the documentation states that the physician performed a nasal scope insertion and examined the interior of the patient’s larynx (this provides a better view of the upper airway than a traditional mirror exam), you would report 31575.

If, however, the physician examines the nasopharynx (that is, the eustachian tubes, adenoids and choanae, or the area where the pharynx and the nasal passages meet at the end of the hard palate), the correct code is 92511, regardless of where the ENT introduces the scope.

One last example: K91.71, Accidental intraoperative laceration of digestive system organ during a procedure on the digestive system.

Coders are often over-coding/reporting when a physician documents that the laceration was expected/incidental/anticipated during difficult lysis of adhesions.

Coders are not always reporting or querying MD for intraoperative lacerations due to clinical documentation improvement (CDI) or other directives at a facility when apparently significant. At the very least, a query should be done on any questionable intraoperative lacerations, as to whether they are truly complications, or expected/incidental/anticipated lacerations.

Programming Note:

Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. EST.