The author of this article consulted with several coding professionals to come up with a list of the nine most common mistakes physicians make when it comes to documentation and coding. The coding professionals also weighed in on what they thought were going to be emerging trends and coding changes that will most likely affect the lives of physicians in the near future.
The 9 Biggest Billing Blunders:
1. Failing to note negatives
The physician must include both the positives and the negatives in order to obtain the proper CPT code for the visit. A good rule of thumb is: “What did you touch and what was the result?”
2. Skimping on substance
Do not oversimplify the notes regarding the patient’s visit. If you spoke to the patient about it, write it down.
3. Use of “noncontributory”
Don’t say “noncontributory” unless you really mean “it wasn’t worth mentioning.”
4. Stuck in the middle
Avoid the habit of coding Level 3 visits. According to Rhonda Buckholtz, vice president of business and member development for the American Academy of Professional Coders, “if they did it and they documented it, they need to code it and get paid for it.” The Physician Practice 2009 Fee Schedule Survey found that undercoding two Medicare patients a week costs physicians more than $10,000.00 a year.
5. Cloning patients
Focus on each patient’s chief complaint, symptoms and duration of symptoms. Do not document the same things for every patient. While the exams for each patient may be similar, the issues that were addressed are not.
6. Electronic over-documenting
Avoid over-documentation by not using the same template for every patient.
7. Overlooking CPT codes
Stay current on the guidelines for CPT codes. Changes to the codes occur frequently and physicians need to be aware of changes, and document/code accordingly.
8. Confusing the coder
It is important for physicians to have complete documentation to support the CPT codes being used. Physicians and coders need to operate like a cohesive team, giving each other the needed information so they can each do their jobs better.
9. Audit aversion
Chart audits uncover gaps between what the physician is documenting and what is being coded. They point to areas of development and potential issues jeopardizing reimbursement. Embrace audits for the benefit of the practice and your patients.