If you are using an outdated code book or your coder or biller enters the wrong code, your claim could be denied. The use of outdated coding books either CPT (Current Procedural Terminology), ICD-9 (International Classification of Diseases), or (Healthcare Common Procedure Coding System) HCPCS, and/or superbills will result in loss of revenue. Insufficient documentation occurs when documentation is inadequate to support payment for the services billed or when a specifically required documentation element is missing. When coding and submitting claims, it is imperative that what is documented is billed. If it is not documented, carriers consider the service(s) were not performed.
However, denials related to insufficient documentation, no documentation, and medical necessities are more complicated because providers must be involved in improving the process. Coders unequivocally play a key role in denials avoidance, and they are best suited to proactively identify process deficiencies by using a proactive, not reactive approach. The following ruling is important to understand how carriers look at errors in billing. Strive to be proactive, not reactive to any concerns, and be sure that practices do not ever fall into the violation of 18 U.S.C. § 1347.
Under that code section, it is a felony to knowingly defraud any health benefit program or to fraudulently receive payment from any health benefit program, and/or under 18 U.S.C. § 1035, which makes it a felony to willfully make fraudulent statements or representations in connection with the receipt of payments for healthcare benefits. This is nothing that practices would ever knowingly do, but not using correct billing, procedures, and protocols could put you at risk. The practice should take no comfort in claiming a lack of knowledge or that they were mistaken about the law should audits occur. The statutes governing healthcare fraud do not provide leniency for a provider’s lack of knowledge, therefore, protocols should be in place for your office to make sure, should you have an audit, that you have mitigated your risk and liability.