5 Common Mistakes in Medical Billing & Coding

In the intricate world of U.S. healthcare, medical billing and coding serve as the financial backbone for both providers and payers. However, even minor errors in these processes can lead to significant financial losses, compliance issues, and patient dissatisfaction. Studies estimate that medical billing errors cost U.S. healthcare providers an estimated $68 billion annually.​

At SHAI (Smart Humans & AI), we understand the complexities of medical billing and coding. With over 30 years of experience, our blend of human expertise and intelligent automation ensures accuracy, compliance, and efficiency in every claim processed. In this article, we delve into five common mistakes in medical billing and coding and how SHAI's solutions help mitigate these challenges.​

1. Incomplete or Inaccurate Patient Information

Errors such as misspelled names, incorrect policy numbers, or outdated insurance details can lead to claim denials and delayed reimbursements. Even a minor typo can cause a claim to be rejected, necessitating time-consuming corrections and resubmissions.​

SHAI’s Solution: Our intelligent automation tools verify patient information in real-time, cross-referencing data across multiple platforms to ensure accuracy. This proactive approach reduces the likelihood of errors and accelerates the billing process.​

2. Incorrect Use of Codes and Modifiers

Misapplication of CPT, ICD-10, or HCPCS codes, including unbundling services or omitting necessary modifiers, can result in claim denials or compliance issues. For instance, unbundling occurs when multiple codes are used for procedures that should be billed under a single comprehensive code.​

SHAI’s Solution: Our certified coders (AAPC, AHIMA) are trained to stay abreast of the latest coding guidelines and payer-specific requirements. We employ AI-driven tools to flag potential coding errors and ensure appropriate use of modifiers, enhancing claim accuracy and compliance.​

3. Failure to Stay Updated with Coding Changes

Medical coding systems are continually evolving, with regular updates to codes and billing regulations. Failure to stay current can lead to the use of outdated codes, resulting in claim rejections and compliance risks.​

SHAI’s Solution: We invest in continuous education for our coding professionals, ensuring they are informed about the latest changes in coding standards. Our systems are regularly updated to reflect new codes and guidelines, minimizing the risk of errors due to outdated information.​

4. Inadequate Documentation and Medical Necessity

Insufficient or unclear documentation can hinder the ability to justify medical necessity, leading to claim denials. Proper documentation is crucial for accurate coding and reimbursement.

SHAI’s Solution: Our Clinical Documentation Improvement (CDI) support services work closely with healthcare providers to enhance the quality and clarity of medical records. By ensuring comprehensive documentation, we facilitate accurate coding and support the justification of medical necessity.​

5. Lack of Regular Audits and Compliance Checks

Without routine audits, billing and coding errors can go unnoticed, leading to revenue loss and potential legal issues. Regular audits help identify patterns of errors and areas for improvement.​

SHAI’s Solution: We conduct regular revenue integrity audits to detect and address discrepancies proactively. Our compliance-focused approach ensures adherence to regulations and helps prevent costly errors before they impact your revenue cycle.​

The SHAI Advantage

At SHAI, we believe in combining the precision of technology with the insight of experienced professionals. Our commitment to excellence is reflected in our outcomes:​

• Achieved a 40% reduction in denial rates for a 500-bed hospital group.

• Secured $1.2 million in additional revenue through HCC chart reviews.

• Maintained a 98.5% coding accuracy rate over 12 months.

• Improved operational efficiency by 30% through process automation.

• Reduced AR days by 6 within three months for a multi-specialty practice.​

Our people-first culture, combined with cutting-edge technology, positions SHAI as a strategic partner in optimizing your revenue cycle and ensuring compliance.​

Conclusion

Medical billing and coding are complex processes where errors can have significant financial and legal implications. By partnering with SHAI, healthcare organizations can leverage our expertise and technology to minimize errors, enhance compliance, and improve overall efficiency.