Seven Details to Check Before You File

Proofing claims prior to submission prevents time-consuming denials later.

By Beth Morgan, CPC, MCS-P

It never hurts to double-check claims for accuracy before you transmit them. The extra step may save you or your customer service department from having to deal with a denial later. Here are seven common problem areas to consider:

Certified Inpatient Coder CIC

1. Do you have the right patient? I personally have witnessed registrars confusing one patient for another because two patients had the same or a similar name. Don’t select automatically the first name that looks like a match: Check addresses and dates of birth to verify you are billing the correct individual.

2. Have you charged for the correct tests, procedures/services that were given or received? For instance, did the physician/provider order one test, but you charged for two? Entering a bill for services/procedures takes concentration, and data entry errors could result in a patient being charged more than once for the same service, supply, or medication. Review the charge slip to verify how many tests were ordered on the day in question.

3. Are the hospital days, rooms, and services billed accurate? An inpatient hospital stay charge should be from the ad-mission date until the discharge date only. For outpatients, charges should be for the actual department in which the patient was seen. For example, was a patient charged for an operating room when the procedure was done in a regular exam room?

4. Are the times correct? As much as we want to charge for every second, something can only be charged in 15-, 30-, or 60-minute increments. Do not “round up” when notes or reports don’t support it. For instance, if the patient was seen for 25 minutes, I would bill one 30-minute session or two 15-minute sessions (as appropriate to the service/code descriptor). If the patient was seen for 16 minutes, I would bill for one 15-minute session.

Recently I audited a bill for a patient receiving inpatient therapy services. The patient was charged for services he could not have received because he was in a comatose state. The bill indicated that several times a day he received over 30 minutes of charges for gait training or therapeutic exercises. Review of the notes showed that he had received only 15 minutes of actual work.

5. Have you over-coded? This is where a more expensive procedure/service is charged when a lesser one would do. For example, a name-brand medication was billed instead of the generic alternative provided; or, a longer office visit that includes paperwork time was reported when only the actual face-to-face time should have been charged.

6. Are the quantities and items correct? Did the patient really have 10 aspirin, or was it just one? Watch out for too many zeros.

7. Are there overcharges or unbundles? Are you charging for items that can be included in the cost of something else? I have seen frequent unbundling of lab panels, for instance.

During a recent audit we discovered that all the components of a comprehensive lab panel were billed individually. When we pointed this out to the facility, we were told the tests always were billed individually because the reimbursement was greater and no one challenged it. This is exactly the type of billing/coding you don’t want to do.

Items associated with the room are another area in which I frequently see hospitals charging inappropriately. Do you pay extra for towels, gowns, sheets, etc., in a hotel? No: They are included in the price of the room. The same should be true in the hospital.

When entering data, I check my work either prior to submission (for small projects), or even every hour (for large projects). Taking a few moments to check over what you’ve entered on the bill will prevent even more time-consuming questions from coming up later.

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