What are some consequences of incorrect coding?

Coding Errors May Lead to Fraud and Abuse Fines

The consequences could be a monetary penalty or a legal issue if the claim is named fraudulent. To prove fraud occurred rather than abuse, the upcoding or miscoding of an event must occur over time and across a large number of patients.

What is the main consequence of billing incorrectly?

Billing errors lead to delayed payments from the insurance companies, denied claims, and increased stress at the very time a patient needs to be stress-free. It is hard for the medical team to provide the highest degree of care when a patient is upset due to a problem with his/her bill.

What could be the potential impact on a patient who was coded incorrectly?

Impact on Patients

Even a mistake as simple as swapping the place of two digits in a code during the authorization process can indicate a wildly different diagnosis. This can cause denials and delay services, revenue as well as destroy the patient experience.

What are 3 potential consequences of down coding?

Whether intentional or careless, repeated submissions of claims with coding errors or inappropriate codes, such as upcoding, downcoding, or inaccurate bundling, can lead to fines or federal penalties for fraud or abuse.

What are three consequences that can happen from inaccurate medical coding or billing?

Inaccurate medical coding will cause your reimbursements to get delayed, denied, or only partially paid. Build up a cache of delayed reimbursements and you’ll have mounds of paperwork, stress, and lost revenue for your emergency medicine practice to deal with.

What is the impact to coding due to the incomplete clinical documentation?

One of the most significant effects of incomplete documentation in a patient’s medical record is inaccurate reimbursement that results in inaccurate gross revenue to the provider. In the absence of accurate documentation, a provider should assume that revenues are not accurate, as well.

Why is Upcoding wrong?

Upcoding occurs when providers report higher-level procedures or services than can actually be documented or by an unsupported medical diagnosis or other facts. Upcoding poses a serious risk of non-compliance resulting in audits as well as charges of fraudulent billing practices.

Why is it important to code correctly?

Accurate coding (and documentation) will provide more accurate payments, prevent denials and delays in payment. … At Signature accurate coding provides quality data for research and public health.

How do you stop coding errors?

  1. Ensure Patient Information is Correct and Properly Aligned with Data. …
  2. Avoid Upcoding. …
  3. Utilize the Latest Medical Coding Manual. …
  4. Avoid Duplicate Billing. …
  5. Verify Insurance Benefits and Coverage in Advance. …
  6. Hire A Professional Medical Biller. …
  7. Improve Your Medical Billing and Coding Systems With Coronis Health.

What is up coding and why is it important to avoid up coding?

“Upcoding” occurs when a healthcare provider submits codes to Medicare, Medicaid or private insurers for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed.

What does down coding mean?

“Downcoding” is the opposite side of the upcoding coin. Typically, downcoding occurs because the provider fails to provide relevant documentation details to assign a service, procedure, or diagnosis to the optimal level of specificity. For example, diabetes is frequently undercoded.

What is jamming in medical coding?

Jamming. – Routinely assigning an unspecified ICD-9-CM or ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code number.

How do you avoid under and over coding?

Steps to Avoid Overcoding and Undercoding
  1. Unbundling—billing separately for multiple components of a procedure that should be billed as a single charge.
  2. Upcoding—using a code for a higher level of service than what was performed or coding for a service not covered by a payer by substituting a code for one that is covered.

Can doctors charge whatever they want?

The provider can set their own fees at whatever level they feel is ‘fair’. However, they rarely, if ever, get what they charge. Their contract with Medicare, Medicaid and other insurance companies obligates them to take what they allow as payment in full for the services they provide.

What are V codes?

V codes, described in the ICD-9-CM chapter “Supplementary Classification of Factors Influencing Health Status and Contact with Health Services,” are designed for occasions when circumstances other than a disease or injury result in an encounter or are recorded by providers as problems or factors that influence care.

How do I stop upcoding and Downcoding?

Periodic chart and coding audits can help prevent upcoding and downcoding. Typically a provider will have 10-20 charts audited at least one to two times per year. An internal reviewer or external reviewer can be utilized. The information is valuable only when it is shared with coding staff and providers.

How do I know my Upcoding?

Currently, there are two main ways to detect potential DRG upcoding: 1) auditing by recoding the original medical charts, and 2) comparison with historical claim data to detect in- creased percentage of higher-cost DRGs (e.g., [8]).

Is Upcoding illegal?

Upcoding is illegal, but there are hospitals and healthcare providers who have been caught doing it. 4 Administrators who run healthcare systems can benefit professionally when their profits are impressive, and upcoding is one way to make that happen by cheating the system.

What is the difference between upcoding and Downcoding?

If the code that is recorded is for a higher level service or procedure than what is documented in the patient’s chart, this is referred to as upcoding. Conversely, if the code that is documented is at a lower level of complexity or cost than what is documented, it is called downcoding.

What is stark and anti kickback law?

The federal government instituted the Anti-Kickback Statute and Stark Law in an effort to eliminate healthcare fraud and abuse. Simply stated, both regulatory laws prohibit medical providers and/or entities from making health service referrals in exchange for compensation of any kind.

How do I report false medical billing?

Reporting Fraud
  1. By Phone. Health & Human Services Office of the Inspector General. 1-800-HHS-TIPS. (1-800-447-8477) …
  2. Online. Health & Human Services Office of the Inspector General Website.
  3. By Fax. Maximum of 10 pages. 1-800-223-8164.
  4. By Mail. Office of Inspector General. ATTN: OIG HOTLINE OPERATIONS. P.O. Box 23489.

What is a Phantom provider?

They’re called phantom providers, which file false claims from offices that don’t actually exist. It’s all an elaborate fraud scheme designed to get insurance companies to pay out on these false claims.

What is abuse in medical billing?

Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.

How common are medical billing errors?

Upwards of 80% of Medical Bills Contain Errors

According to Pat Palmer, CEO and founder of Medical Billing Advocates of America, his organization finds errors on three out of four medical bills they review. While patients are frequently overcharged, hospitals and providers are very good about never undercharging.