The recent and ongoing issues with the pandemic contributed to an increase in errors in medical coding, but this has always been an issue for healthcare providers around the country. In a recent study, about 16% of hospitals reported denial rates on claims of 8-10%, and about a third of hospitals reported denial of claim rates of more than 10%.

For healthcare systems across the country, reducing medical coding errors will have a direct positive result in their revenue cycle management. With an increase in clean claims, a decrease in denials, and an increasein reimbursement rates, healthcare systems will enjoy a top return on their investment when moving to outsourced medical coding, revenue cycle management (RCM), and health information management (HIM) partners.

Errors in Coding

Recognizing common errors in medical coding is the first step in understanding the benefits of outsourcing this critical part of the revenue management cycle. The denial of claims issue is a significant issue for all healthcare systems, with over $262 million in initial denials in 2016. With the pandemic, these numbers have only increased with additional pressure on the system due to staffing shortages and increased healthcare service demands.

Not completing the required data and documentation is one of the leading causes of claim denials or claim processing delays. This typically occurs when coders do not link the required components on the claim or the lack of information entered into the system by the physician.

Incorrect Descriptions

Billing for practices that are incorrect based on the description of an injury are typically an immediate denial of the claim. These are often unintentional mistakes, such as coding for a procedure on the leg when the patient’s injury is indicated as an injury to the arm. One way to alleviate these common and overlooked mistakes is to use an RCM partner that offers end-to-end solutions.

Incorrect Procedures

Upcoding is billing for procedures that were not complete or billing for more involved and complex procedures than what the patient received. In some cases, billing can occur for a procedure that was not done, which can be a factor of coding for the wrong treatment or a mistake in reading and understanding information entered by the doctor. In addition, it is important to code and bill at the appropriate severity level.

Overlaps and Excluded Diagnosis

Overlapping medical coding or using a code that is not consistent with the listed diagnosis is typically a red flag on a submitted claim. These are typically coder errors that can be reduced or eliminated by choosing an RCM partner that offers state-of-the-art technology in artificial intelligence and automation of systems to avoid these issues.

The Human Factor

It is possible to add training and ongoing oversight to in-house medical coding teams. Unfortunately, with the current state of labor shortage across healthcare systems, this becomes a very difficult task to manage.

In addition, no matter how well-trained people are, there is always the human error factor. People entering data are likely to make mistakes, either by incorrectly coding an item or making a common data entry mistake that inverts the code or otherwise creates an error in the entry.

Most medical coders are extremely careful about these issues and take pride in having a high clean claim record. However, the more they are under stress and pressure to enter large amounts of data due to the high patient and treatment volumes combined with fewer professionals to do the job, the more likely human error becomes a signficant factor in medical coding throughout healthcare systems.

This is not just for large hospitals and treatment facilities. These same issues occur in small practices and specialist offices, with claim denials and delays of reimbursement from payers often having a very significant impact on the ability of these smaller healthcare providers to remain viable.

Partnering with an RCM partner,such as GeBBS Healthcare Solutions, that uses a state-of-the-art medical coding platform or coding audit platformis a cost-effective option for most healthcare systems. These partners use computer-assisted coding practices that are managed by experts, ensuring increased efficiency and decreased error rates.

The result is a higher productivity level for RCM, often as high as 30%, with an increase in clean claims and a decrease in claim denials. This translates into a more efficient revenue cycle, timely reimbursements, and increased reimbursement rates.