How do you handle claim rejections due to coding errors or mismatched services?

In my experience of mismatch codes. For example patient visit was outpatient surgery the coder didn’t codes diagnosis code to match CPT or front end staff fail to get authorization from payer. The claim was rejected by the payer with claims error code not medical necessity or lack benefit coverage

In my opinion I 100% agree with this which is often overlooked when billing out the claims. That’s why it is key to do the prior eligibility run, check documentation before adding DXcd, Pcd, modifiers etc…

Coding errors occur when incorrect medical codes are used to describe diagnoses, procedures, or services provided. Mismatched services happen when the codes do not accurately reflect the services rendered, leading to discrepancies between the claimed services and the actual services provided.

The coder role starts after the provider has documented the DX codes along with the procedure details, and their roles are very important in the RCM. It is a general practice to code very precisely after carefully checking the medical records. We can ensure the proper education and training program to make the coders aware of up-to-date guidelines.  Their thorough review only determines under which level of service the claims need to be submitted. If the insurance is rejected regularly due to any specific reason, we can check what the requirements are for that type of medical condition.  We can have an automated tool to check the coding in the backend while submitting the claims, like Clearhouse.

There is lot of way it can go wrong, if we did not create proper check and edit in PMS itself to avoid additional transaction cost from Clearing house. Few are Dx, modifiers and even some times CPT

What creates complexity in prevention of errors is that there is little standardization in payer requirements. Rules and guidelines can differ by payer and can also vary within each payer by group or plan. A lack of consistency in these requirements leaves providers at a disadvantage and causes unfair administrative costs.

To avoid unnecessary denial from payers every CH has their own edit to avoid and easy fix in coding errors. Even if your practice getting more coding denials we can set rules in PMS as well as in CH

Insurance companies rely on accurate coding to process claims. Coding errors and mismatched services can result in claims being flagged as incorrect or fraudulent, leading to rejections. These errors can disrupt cash flow and delay reimbursements, impacting the financial health of healthcare providers.

Reading the above paragraph brings visions of staff manually reviewing every claim for every payer's myriad of rules before submission. Intuitively, we know that coding tools and payer documentation help organizations to create rule logic in their billing systems to verify accuracy and completeness, verifying eligibility, benefits and authorization requirements as part of the process. Without standardization of how those requirements are made available to providers, however, we are still in an archaic world where those requirements are gathered and interpreted manually. For this reason, managing denials still requires a high-functioning team of operational and IT folks working on lockstep to manually build those requirements as rule logic.

4 possible measures that I advocate for avoiding coding errors & the ones impacting medical billing services positively includes, Adaptability : Coding updates are inevitable. Embracing a culture of adaptability and staying ahead in understanding and implementing these changes is crucial. Precision : Detailed and accurate documentation isn't just a formality; it's the cornerstone in navigating through coding updates successfully. Team Collaboration : Building a team that understands the importance of coding accuracy and compliance is integral to a seamless revenue cycle process. Continuous Education : Regular staff training & keeping abreast of the latest industry updates are paramount in mitigating errors and reducing compliance risks.

Edit is the better solution to avoid this. Charge entry most of PMS made it automatically with out any manual intervention from EHR itself. We can scrub the claim and make it mandatory to review by manual activity will reduce this. But this is not end or long term solution

To prevent these issues, implement robust training programs for coding staff to ensure they stay updated with the latest coding standards and guidelines. Utilize coding software and tools that can help reduce errors. Regularly audit and review coding practices to identify and correct mistakes before claims are submitted.

Although remittance advice and remark codes (RARC) are standard, how a payer applies them is non-standard. Some payers faithfully use remark codes, some do not. A combination of remittance code and remark code can mean different things, even within the same payer- and finding two payers that use the remittance codes the same way is more of the exception than the rule. In short, finding the commonalities amongst denial data requires consistent and thorough analysis and a written, carefully thought strategy. Moving towards automated responses to denials, will require clear conversation and testing methods to ensure automated responses are taking the correct actions. Denial actions that create incorrect claims will add to the denial problem.

When claim rejections occur, promptly review the rejection reasons and identify the specific coding errors or mismatched services. Correct the errors and resubmit the claims with accurate information. Establish a process for tracking and analyzing rejections to identify patterns and implement corrective actions to prevent future occurrences.

The effective coding practice will take pivot role here. Adding appropriate modifiers when it's necessaryz especially when we code the surgery CPT along with the ECG/EKG and radiology codes and specificy the place of service exactly might support the claim. Choosing the very precise DX codes will obviously lead the claims for the payment. Defining the coding level especially when comes for E/M CPT coding, the claims might not get denied in full however change of downcoded payment might occur. One more denial but it's not the actual coding related, but require the medical records to substantiate the services performed and claims get reimbursed...

Great reminders on issues that continue to plague the revenue cycle. It is important to remember that coding errors, mismatched codes, and also missing or incomplete codes don’t always lead to claim rejection. In many cases they are paid, but not for the full extent of services or severity/complexity of services that were provided. This often results in the provider being significantly underpaid. Worse, provider systems don’t recognize the underpayment because they can only compare payment to the codes that were entered. Having an audit process in place even on “correctly” paid claims is burdensome, but can recover significant unrealized revenues and identify root causes that reduce future errors.