Medical coding and medical billing are two closely related aspects of healthcare operations. Both of these are extremely vital to the revenue cycle, ensuring that healthcare providers are adequately compensated for the services provided.
Both coding and billing require expertise and a great deal of labor. Further, both are beset with challenges with financial and legal implications. A single mismatch of codes can lead to claim rejection, for example, and overcoding can result in a liability investigation.
Let us learn the most common challenges in medical coding and billing along with ways to overcome them.
Common Issues in Medical Coding and Their Solutions
Medical coding standardizes and simplifies documentation between different medical facilities. However, the tough task is considering the amount of information that has to be coded. For instance, the ICD-10, the globally used code book, has more than 70,000 codes for diseases. Combine that with the number of patient visits—around 1 billion in a typical year, according to the US CDC—and the vast volume becomes enormous.
Let’s understand some of the common challenges in medical coding with ways to address them.
1. Training and education
Apart from knowledge of the codes, medical coding requires familiarity with medical terminology, diagnoses, and procedures. In this regard, training and education remain a significant challenge. Despite the importance of medical coding, literacy in the subject remains demonstrably low. Compounding the challenge is the frequent changes to the medical coding systems.
Continuous training of in-house coders is thus necessary. This will enable them to stay up-to-date with coding guidelines and technologies as well as with the changing regulations. An alternate option is to rely on professional medical coding services. A specialized company has certified coders whom healthcare institutions can partner with to acquire the required service.
2. Poor documentation
In stark contrast to the large code set, insufficient or poor documentation presents another huge challenge to medical coders. Thorough and clear information about a patient’s diagnosis, medical procedures, and treatments has to be furnished. But this is sadly not always the case. Healthcare providers may omit important details or the reports may be illegible. This is made worse by the fact that providers are not always available for clarification. A proper communication channel is the best way to overcome this challenge.
3. Outdated code sets
Medical coding sets get revised and updated frequently. The ICD maintained by the WHO and the CPT by the American Medical Association—two widely used code manuals—are updated yearly. The updates are mostly related to the addition of new diseases and technology procedures. But the changes can be drastic sometimes. The CPT 2023 added 225 new codes and deleted several others. It is important for coders to learn the new codes as they change and use them correctly.
But updates in codes also present new challenges. One is that the current codes and guidelines may be different from those used at the time of service. So, while knowledge of the latest coding manual is important, one must not forget the old codes. This is essential not only for resubmitting denied claims but also for accurate audits.
4. Timeliness of coding
Payers have policies that require claims to be submitted within a specified period after the date of service. If a claim is received after the specified date, the claim is rejected. Delays in coding and thus submitting claims can cause substantial loss in revenue.
Constant changes in code sets, numerous regulations, and a need for more skilled coders are some major bottlenecks. Partnering with a dedicated medical coding company can be the most viable solution in such a scenario. They can help increase efficiency while coding at the highest level of specificity.
Challenges in Medical Billing
The issues in medical coding translate to billing. If coding is not done to perfection, then there is a drastic impact on billing, resulting in unclean claims. Let’s understand some of the most common challenges surrounding medical billing.
1. Insufficient patient information
Incomplete or inaccurate details about patients, such as their name, sex, date of birth, insurance ID, and medical history, present a big challenge to medical billers. The entry points for errors are many. Patients’ data may not be fully collected at the initial point of contact or not verified. Keystroke errors while entering patient information in an electronic health record is also an entry point.
2. Inaccurate charge entry
Charge entry errors can occur as a result of slip-ups in data entry, missing specific billing or patient reference data, and incorrectly mapping services provided to their charges. Charge entry issues have consequences for multiple stakeholders—the service provider, patients, and the payer.
To reduce charge entry mishaps, verify and double-check the patient’s details. Scrub your claims and ensure that correct medical billing codes and modifiers are assigned.
3. Duplicate billing
This can happen when a claim is submitted without checking whether the service has been paid or filed. Duplicate billing can be a major issue for the billers as well as the payers, because it may seem as though the patient received the same service twice, and thus has to pay twice. Besides the administrative hassle, duplicate billing can result in loss of reputation.
4. Claim denials and rejection
Unclean claims may either be rejected or denied. Keeping track of refused claims can be difficult and re-submitting them tedious as well as costly. It is thus not surprising that more than half of denied claims are never submitted again, according to a study by the Medical Group Management Association.
Rejections and denials are unavoidable but they can be reduced. And thankfully most causes are within the control of providers. Ensuring that an adequate system is in place to verify that claims are clean before they are submitted is a good start. This may require extra work, but having the claims clean in the first go will save plenty of time and money.
Treating the Challenges
Medical coding and billing are fraught with challenges with operational, financial, and legal implications. The issues are endemic and cannot entirely be avoided. But they can be reduced. For this, it is necessary that coders and billers are familiar with the services healthcare providers offer. And they should have knowledge of the common diagnoses and procedures associated with those services. Staying current with coding and billing guidelines is also essential.
Another pragmatic approach is to outsource medical billing and coding services to a third party with expertise and experience. Outsourcing can help bypass most of the challenges associated with billing and coding. A specialized medical billing and coding company has professionals with requisite certification, has systems in place for verifying information, and knows the guidelines. Working with it can save costs as well as increase efficiency.
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