Both the government and private insurers are becoming increasingly stringent when it comes to medical billing practices, with audits revealing cases of both fraud and abuse. While providers deserve to paid in full for the services they provide, it is essential that billing practices that might be construed as fraudulent or abusive be avoided. This is one of the keys to avoiding legal troubles and maintaining a thriving practice.

Let’s break down the two categories of errors discussed above:

1. Fraud: Refers to cases where there was an intentional misrepresentation.
2. Abuse: Refers to cases where the error in question was an innocent mistake.

These definitions are according to the AMA’s Principles of CPT® Coding, ninth edition. An easy example of abuse would be a provider erroneously coding for a more complex procedure than was actually performed due to misunderstanding the codes involved.

To make life easier for providers, the AMA provides a variety of resources to help with medical billing and coding. The above linked page on the AMA website contains resources to help with COT codes, ICD-10 codes, HCPCS codes and various other resources that can help physicians with medical billing and coding.

For more help, we’ve identified 8 common errors that providers should avoid:

1. Unbundling

Unbundling refers to using multiple codes to capture all the component parts of a single procedure, when there is a single code that could cover all of it. This is done either due to misunderstanding, or in an attempt to increase payment.

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2. Upcoding

Upcoding is when a code is assigned to a procedure that is more expensive than the actual services rendered. An example would be an oncologist, a field with highly complex conditions, reports the highest level of E/M code for a patient encounter, regardless of the actual procedures that occurred. While this isn’t always upcoding, providers should be careful to only use codes that accurately describe services provided based on the patient’s condition.

3. Not checking National Correct Coding Initiative (NCCI) edits when reporting multiple codes

The NCCI was developed by the Centers for Medicare & Medicaid Services to help physicians ensure that proper coding methods are followed, and that incorrect Medicare Part B claims are avoided. These are automated prepayment edits that analyzes codes billed for a specific patient on a specific date to see if an edit exists within the NCCI. Should an edit exist, one of the codes is denied. The edits also typically include a list of CPT modifiers that can be used to override the denial. If no such codes exist, clear direction is provided that the denial cannot be overridden.

4. Appending errors

This involves not appending appropriate modifiers, or appending inappropriate modifiers. An example would be adding a modifier that indicates bilateral services, when the code itself already includes bilateral services.

5. Overuse of modifier 22, Increased Procedural Services

Modifier 22, which indicates increased procedural services, cannot be used freely on any procedure. When using this modifier, proper documentation is required to explain why the procedure require more work than usual.

6. Improper reporting of infusion and hydration codes

Infusion and hydration codes are time based. Proper documentation for the start and stop times are necessary for coders looking to bill these services.

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7. Improper reporting of injection codes

For sessions where multiple injections take place, only a single code should be used to describe it, instead of multiple codes describing every single injection.

8. Reporting unlisted codes without documentation

Should unlisted codes be necessary for properly billing a service, proper documentation must be provided.