Common Challenges And Mistakes In Professional Fee Coding
In response to the demand to grow in scale and capabilities, many hospitals have actively pursued physician group acquisitions in recent years to expand their integrated physician networks. This has led to a significant increase in the volume of profee coding handled by hospitals' coding departments.
Due to a lack of experience and training in provider-oriented code, these teams often suffer. Poor professional fee coding endangers the hospital and clinicians' offices. Inconsistent or incorrect profee coding also poses compliance risks for large health systems with complex physician networks. Payers also evaluate population health and quality using claims coding data. Due to erroneous profee coding, claims-based quality reporting puts providers' quality ratings at risk.
The following are some of the challenges in professional fee coding that numerous hospitals and health systems around the country see.
1. Professional E/M Level Selection Criteria Based On Facility Guidelines
The assignment of E/M codes for professional and facility fees is quite different, despite the fact that both types of coding use E/M codes. The facility may employ a resource utilisation point system to choose the appropriate E/M code. On the professional fee side, choosing an E/M code mostly depends on the effort and cognitive labour performed by the provider.
Documentation rules used by profee coders often include sections for a patient's medical history, physical examination, and clinical reasoning. The E/M level selected by the facility and the professional for the same patient visit may vary. Inaccurate service level determination may result from the erroneous application of facility guidelines during E/M code selection. There is a risk of financial loss if a provider chooses an E/M code based on the facility's rules, as this could result in an underestimation of the value of the service provided.
Inadequately conservative coding practices can easily lead to substantial revenue losses. Under-coding is considered a false statement under the False Claims Act, so when it becomes routine, it raises red flags that put hospitals at risk of audits and penalties.
2. Incorrect Procedure Codes
A different operation could be coded into the system if the proper key isn't pressed at the right time. Mistakes in coding the underlying documentation before it reaches the medical billing department can also lead to this issue. If your practice is having a higher-than-usual number of claims rejected due to inaccurate coding, it's possible that your employees aren't using the proper guidelines. Knowing the importance of precise coding might help you make fewer mistakes.
3. Mishandled Overpayments
Sometimes, claims fail to process correctly because the payer has paid too much or too little. Claims that have been underpaid must be corrected immediately, and underpayments must be handled similarly. If appropriate, interest payments should be processed accurately by both parties, and if a payer fails to follow the proper procedure, the provider should quickly tell them.
4. Missing Or Incorrect Information
Claim denials due to omissions are common, and the solution is simple. Before submitting your claim, it's best to double- and even triple-check all of the fields. Problems might arise from missing or incorrect information, even if it's something as seemingly inconsequential as a name, address, sex, insurance information, birth date, etc.
Occasionally, a significant holdup can be caused by inaccurate patient data being entered into the system. It has even happened that the data was entered into the wrong patient record, adding even more time to the process. A denied claim may result from a mistake made by a billing employee entering the information provided without verifying for discrepancies. Mismatches are often missed because billing offices are overworked.
5. Healthcare Tech Errors
Although modern medical technology is a considerable improvement, it also has its fair share of complexities. If patients are to receive high-quality treatment and worry-free follow-up, the billing procedure must be as straightforward as feasible. No one wants to deal with payment delays for telehealth services because of improper use.
To sum up, hospital coding teams are pressured to meet demand while remaining compliant. Hence, professional fee coding is in demand as health organisations integrate physician networks and unify billing and coding. Many hospitals have excellent inpatient and outpatient coding departments, but they often lack the expertise to appropriately code the professional fees of doctors in the hospital's integrated physician network.