Are Coding and Billing Mistakes Hurting Your Medical Practice?

By Dina Petrutsas, CPA
Wednesday, April 12, 2017

In today’s healthcare environment, it is imperative to ensure your medical practice performs its billing and coding function at the highest level possible.

Dina Petrutsas, CPA

In many cases, billing and coding mistakes can cause revenue to decrease; they could also result in overpayments. Either way, these mistakes could be costly.

Let’s first address the common billing and coding mistakes that occur in a medical office, and then we will review the consequences for these mistakes.

The revenue cycle begins when your front desk staff initially talks with the patient and schedules the appointment. Part of this important phone conversation is to obtain the patient’s insurance information to ensure the patient’s insurance coverage is in effect, and to learn the patient’s responsibility for copayments, deductibles and other out-of-pocket expenses. Incorrect insurance information can delay care, because the patient’s insurance information cannot be verified prior to being seen, and payment, if the patient was seen without having his or her insurance information verified. If the medical record does not document the services provided or the reason for medical necessity, the claim could be initially denied, or perhaps only a few of the CPT codes will be paid, while other CPT codes receive a “zero payment.” What does your staff do when they receive an explanation of benefits (EOB) notice with a “zero payment”? Do they post this on the patient’s billing record as a write-off/adjustment, or do they contact the insurance payer to ask why the CPT code was not paid?

Other common mistakes include using outdated or incorrect CPT and ICD codes or not using modifiers when needed. Each of these mistakes could affect the payment to your medical practice. While the amount of the incorrect payment may be small, these small amounts could have a huge impact over a period of time. As an example, based on the 2016 Medicare Part B Fee Schedule for the San Antonio area, the difference in payment between a 99213 and 99214 is approximately $33. While $33 may not seem like a significant amount, consider if this difference were based on 200 patients. The difference then becomes $6,600. Just as under-coding has a negative effect, over-coding can have consequences, such as an audit performed by the insurance payer.

Incorrect billing and coding practices can create complaints from patients who feel the medical practice may have overcharged for the visit. If this occurs, hopefully a patient will contact the practice and ask to speak with a billing representative or the practice manager; however, the patient could complain directly to his or her insurance company. Depending on the outcome of the patient’s phone call to the insurance company, and if the insurance company received other patient complaints about your practice, this could trigger an audit and allegation for filing fraudulent claims. Audits take time to defend, and could result in the practice having legal bills to defend billing and coding policies.

The media has printed articles in the past advising patients to review their medical bills to ensure they reflect the medical services provided. Refer to a U.S. News & World Report article dated Sept. 8, 2014, titled “6 Questions You Should Ask Before Paying Any Medical Bill.” The article instructs the patient to verify the various services listed were actually provided, as well as other tips to ensure they are being charged correctly.

Prevention and staff education are great tools to implement and can help avoid billing and coding problems. How involved are you in the billing process? Do you meet regularly with your practice manager to review reports, such as write-offs and adjustments, denials and appeals, and precollection reports? We recommend the physician leadership meet with their practice manager at least monthly to discuss the financial health of the practice.

Your medical billing and coding compliance plan should address periodic billing and coding reviews to ensure you have sound policies and procedures. These reviews can be conducted internally or by an external company, such as Concordis Practice Management LLC. We would be happy to talk with you regarding a billing and coding review, which is performed by our Certified Professional Coders.

Visit Concordis Practice Management LLC at or call 210-704-1014 for more information.