7 Top Billing and Coding Errors to Avoid

  1. Duplicate claim submitted — Claims are often denied as duplicates for the following reasons:
  • The claim was previously processed (i.e., no payment made, allowed amount applied to deductible on the initial claim). The provider re-files the claim to “correct” it. The second claim submitted is considered a duplicate because the initial claim was processed correctly.
  • The provider automatically re-files the claim to seek payment if the initial claim has not been paid within 30 days.
  1. Non-covered services — Medicare defines many “exclusions” such as:
  • personal comfort items
  • self-administered drugs and biologicals (i.e., pills and other medications not administered by injection)
  • cosmetic surgery (unless done to repair an accidental injury or improvement of a malformed body member)
  • eye exams for the purpose of prescribing, fitting or changing eyeglasses or contact lenses in the absence of disease or injury to the eye
  • routine immunizations
  • routine physicals
  • lab tests and X-rays performed for screening purposes
  • hearing aids
  • routine dental (care, treatment, filling, removal or replacement of teeth)
  • custodial care
  • services furnished or paid by government institutions
  • services resulting from acts of war
  • charges to Medicare for services furnished by a physician to immediate relatives or members of the same household

Stay up-to-date on current exclusion policies by checking with your Medicare carrier and/or its website for changes. Most contractors will post changes to policies and their effective date.

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  1. Lack of medical necessity established — The claim will be denied because the payer does not deem the procedure for this diagnosis to be a “medical necessity.” Check the particular carrier or contractor for the list of covered diagnoses for a particular service.
  2. Inappropriate bundling of services — This indicates a lack of awareness of the National Correct Coding Initiative (NCCI) edits that govern appropriateness of tests being performed together on the same date of service. Access the NCCI Edits on the Medicare website to review which codes may be billed together on the same date of service.
  1. Beneficiary eligibility — Claims often are denied for eligibility because:
  • The beneficiary number is invalid on the claim
  • The beneficiary is not eligible to receive benefits
  • The beneficiary’s claims must be filed to another insurance plan
  1. Incorrect carrier — Check the patient’s insurance card and verify the Health Insurance Claim (HIC) number on the card. Patients with traditional Medicare coverage will have a HIC of nine digits, followed by an alphanumeric suffix.
  2. Incorrect Diagnosis — Assigning a covered diagnosis does not mean you automatically can perform any procedure that exists for the covered diagnosis. Documentation in the medical record must justify why the procedure was necessary to treat the patient’s diagnosis. 8. The claim is missing a modifier or has an incomplete or invalid modifier — Misuse and abuse of modifiers (particularly modifiers 22, 25, and 59) is under Office of Inspector General (OIG) scrutiny, and can result in significant penalties.
John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

2 Responses to “7 Top Billing and Coding Errors to Avoid”

  1. Nina Leeth says:

    Some routine immunizations (such as flu shots) are covered. Some routine physicals (such as the “Welcome to Medicare Exam”) are covered. Some x-ray and lab tests are covered for screening purposes. For example, a screening mammography is covered for the diagnosis of screening for breast cancer. A prostate specific antigen or PSA lab test is covered to screen for prostate cancer. There are other exceptions, these are just a few of the examples. It would be a good idea to mention that there are exceptions, and that these are not absolute exclusions.

  2. Vishnushanam says:

    Hi,
    I would like to prepare for CPMA exam. Please give me instructions for preparations.

    Thank you.

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