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Fixing common billing and documentation errors


San Bernardino, CA-Fixing common billing and documentation errors could mean improvements of up to 35% to your bottom line, according to Donna McCune, CCS-P, COE.

McCune, vice president of Corcoran Consulting Group, advised selecting the proper level of service for exams and consultations. "We tend to miscode evaluation and management (E/M) services, oversimplify, and avoid level five," she said.

She recommended using eye codes instead of E/M codes. "Eye codes are much easier to satisfy and pay at a higher level of service," said McCune. "The definitions are simple and documentation is easier to understand. These will continue to grow in use."

McCune said ICD-9 codes should be selected carefully. "When you think about diagnosis coding, make sure to use the most descriptive code with four to five digits, and link the diagnosis code to the procedure," she said. "Code the symptoms if no definitive diagnosis is determined. Do not report rule-outs, questionable, etc.

"All claims must be supported by chart documentation," she reminded. "It starts right at the top in the chief complaint." The chief complaint supports the service and justifies charges. McCune suggested that chief complaint data should be noted in the patient's own words, if possible. She added, "Clinical staff should be educated and understand that they affect billing and the claims process with what they write in the chief complaint section."

Proper documentation is also essential for diagnostic tests. McCune explained that three things should be included: the physician's order, the test, and the interpretation (test findings and assessment, plans for treatment, etc.).

McCune went on to discuss the importance of operative reports, which are often overlooked for surgeries done at private practices. "There should be an operative report for each procedure that outlines preop and postop diagnoses, indications for surgery, description of surgery, and discharge instructions," said McCune.

She also advised to document indications for surgery, describing medical necessity, and to document the complexity of the surgery (i.e., what you did differently for this specific patient).

Missed charges

Another area that is fraught with errors is charge capture. "Finding missed charges is a very difficult thing to do. Make sure that you are paid for the work you do. Check off all services ordered and provided," said McCune.

Common missed charges include exams to determine the need for surgery, exams on the day of a minor procedure, diagnostic tests, additional surgical procedures, and prosthetic devices.

Claim errors

"Submitting clean claims ensures that you get paid quickly," reminded McCune. She listed accurate patient information and effective use of modifiers as two ways to generate successful claims.

"Get it right the first time," urged McCune. "It starts at the front desk. Be sure your staff is trained and collecting the correct patient information from the start. Also, train staff on modifiers, including what they mean and how to use them correctly."

It is also important that staff is knowledgeable about local coverage determinations. "Make local carrier Web sites or the Centers for Medicare and Medicaid Services Web site available so that your staff knows the coding and documentation criteria for specific services," said McCune.


McCune advised, "You want to do what's medically necessary, of course, but do you know what Medicare's benchmarks are? Deliver commensurate care for the presenting problem. For example, use a short exam for an acute problem and a complex exam for a catastrophic condition. Invite a patient back for a comprehensive examination when appropriate."

Utilization should be tracked and compared with benchmarks. The American Academy of Ophthalmology's Preferred Practice Patterns can be used as a guide and gives indications and standards of care and frequency.

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