What Happens if a Medical Coder Makes a Mistake?

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Medical coding is a hugely important part of the billing process within the United States healthcare system. The coding applied to treatments and services is like a language used between medical professionals and payers such as Medicare, Medicaid, and insurance companies.

Medical coders translate all parts of a patient’s file into coding before it is billed and sent for payment. It is vital that medical coding is done accurately, say the experts at findacode.com, because mistakes can be very costly.

 Medical Coder

Why Accuracy is So Important?

With so many different codes and various coding structures to consider, it is important that a medical coder is accurate when doing their job. A simple mistake could mean the difference between $100 and $100,000 in payments for the healthcare provider.

If a claim sent to an insurance company is missing vital information or has errors in coding, it may be denied by the payer. This could also be due to lack of sufficient cover by the patient. When a claim is denied, it will be sent back to the healthcare provider with a detailed reason for the denial. The healthcare provider can appeal the decision; in some cases, it may be sent back for reprocessing. Even if the claim is reprocessed and paid, it has cost the healthcare provider time and money. The claim must be checked and amended but know that the delay in payment could cause problems with the efficient running of the medical facility.

Nevertheless, inaccurate coding can result in more than just lost revenue. If the medical facility is making mistakes on billing forms regularly, it could then come under scrutiny. Constant mistakes when billing for medical services could be classed as medical abuse and fraud, and if it is deemed that a practice has made false claims that resulted in monetary gain (whether these were deliberate or not), there is likely to be fines or even a prison sentence.

In the case of false submissions to government agencies such as Medicare and Medicaid, which are classed as violations of the Federal Civil False Claims Act (FCA), the law does not require any intent, so coding mistakes can be very expensive. This is especially so when you consider that fines can be up to three times of the amount the government paid out because of the false claim. Add to this penalties of more than $22,000 per falsified claim and you can see how mistakes can become very costly.

Why Mistakes Happen

It is so important for medical coders to keep up to date with the coding system as changes tend to occur yearly. Without the right codes, the claim is likely to be returned to the payer. It is necessary for claims to be completely accurate to ensure the turnaround is smooth and without any issues.

But coders often have their work cut out. Physicians are well known for their difficult-to-read handwriting, and it is quite common for them to omit essential information. Sloppy paperwork may result in a coder using an incorrect billing code.

A mistake that commonly leads to false claims and over payments is un bundling, which is when a coder will use separate codes for a series of procedures that can be linked under one code. Up coding is where a coder will use a billing code for a procedure that was much more expensive than the actual procedure that was used. Un bundling and up coding are illegal and can result in dire consequences.

As mistakes can have profound consequences for a healthcare provider, it is vital that coders take attention to detail seriously when completing their work.

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