Common coding mistakes and how AI is resolving them

If a medical student’s classes reflected the reality of practicing medicine today, I would venture that more than half of the curricula would be focused on performing administrative work, including the very complex task of coding.

Accurate coding is one of the most intricate and often frustrating tasks that doctors and staff must do. Countless studies and surveys are in consensus that administrative burden is the most cited contributing factor for physician burnout, an escalating problem that existed long before the COVID pandemic. Erroneous coding can bring significant financial duress to a medical practice, either in the form of decreased revenue, audits, or even clawbacks from private insurers and revenue audit contractors (RACs). Lower reimbursements, creating pressure for doctors to work longer hours and bill more, as well as compliance requirements, are also leading contributors to physician burnout.

Top Five Coding Mistakes – Where You’re Losing Revenue

Inappropriate E/M Coding: Coding for evaluation/management services is often either too aggressive or too passive, and these coding errors are largely attributed to misinterpretation of E/M coding guidelines and the frantic pace of the clinical environment. Aggressive coding occurs when there isn’t proper documentation to prove out what was done. On the other hand, passive coding doesn’t take the entirety of the work performed into account.

Missing E/M Codes: Oftentimes, this is the result of incomplete charting, typically due to provider distraction. Charts without follow up typically result in the claim being sent late or unbilled.

Inaccurate Capturing of Patient Status: The confusion between whether a patient is new or established, which should usually be established at the front desk, can lead to lower payments if the patient’s status is not properly captured.

Missed Administrative Procedure Codes: Providers often miss administrative procedure codes for minor treatments, which can be a significant amount of lost revenue. This includes codes for injections, immunizations, immobilization, etc. Administering injections is among the most routine services provided in a primary care or urgent care practice, but one inoculation includes two codes: a CPT code for the injection, and a separate code for the medication or vaccination provided. Modifier 25 may also be applied if other care is being given. Another example of oversight can occur when placing a splint on a limb. There are two codes to enter: one for the application and another code for the supply item, such as a splint or a cast.

Inaccurate Utilization of Modifiers

The largest errors are the improper use of modifiers 25 and 59 to expand treatment, which can lead to audits and clawbacks. Modifier 25 should be appended to an E/M code to report a significant but separately identifiable additional service rendered during the encounter, such as an injection. Modifier 59 is used to identify procedures/services other than E/M services that are not normally reported together but were appropriate to render under the circumstances.

These are only five areas of improper coding that lead to lost revenue; however, focusing on this list should make a significant, positive difference for the financial and operational well-being of your medical practice.

How Artificial Intelligence is Helping Practices Fix Coding Issues

Revenue Cycle Management (RCM) solutions, powered by artificial intelligence (AI) and machine learning (ML), are augmenting – not replacing – humans, helping them think, work smarter, and minimize costly mistakes. At the root of AI-powered RCM is automating coding, which allows practices to optimize their coding, helping eliminate errors and missed tasks where most revenue is lost. These solutions interface with a medical practice’s EMR and practice management systems either through a process automatic route using bots, or through application programming interfaces (APIs). RCM solutions can increase practice revenue by as much as 25 percent in some instances.

While some may fear the idea that AI will replace them, adopters of these robust solutions quickly find this is not the case and, if anything, find greater security in a more profitable practice where their time is used more efficiently.

When deploying the help of a robust AI-infused solution, the proof will be in specific, measurable results. As an example, an urgent care provider with four locations recovered about 25 percent of lost revenue over the span of a year – and they continue to recover significant revenue on an ongoing basis that otherwise might be lost. The claim lag time also dropped by more than 95 percent, increasing cash flow even further. But beyond these numbers, the staff has become more proficient and efficient. Notable highlights include:

1. Compliance is increased, assuring the practice is documenting to the highest industry standards.
2. Documentation improvement areas are identified, allowing provider to address specific issues and, if necessary, additional training
3. E/M coding is correctly capturing the medical-decision-making and time the physicians take when rendering to their patients.
4. Patient care is standardized across the practice.

The availability of AI-driven systems is a breakthrough tool that is helping practices receive accurate payments and collect all of the revenue they have earned. These platforms can immediately analyze patient encounters and recommend corrections as easily as spell-check corrects your typos. Feedback provided to staff about these issues can help them code more fairly and accurately. And, beyond the numbers, these solutions greatly relieve staff of cumbersome, stressful administrative burdens. The patient experience, with less billing errors and improved pricing transparency, is also enhanced.

Roni Berlin, BSHCM, CPC, CPB, who serves as associate vice president at ExdionRCM Solutions, is a recognized expert in business strategy and analysis, medical coding, collections, and client support. The company’s solution, ExdionACE, is a powerful yet simple AI-powered coding, revenue integrity, and CDI (Clinical Documentation Improvement) solution.