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Seven Common Medical Billing Myths that are Costing Your Practice

April 29, 2020

Medical Practice ChallengesIf you fail to get paid for the services and procedures rendered by your medical practice, all the effort you spend treating patients won’t keep your practice afloat. Unfortunately, according to Healthcare Finance, out of the $3 trillion plus in medical claims submitted each year, around $262 billion in claims get denied, which can do a number on your bottom line. And even when claims are recoverable, appealing claims comes with its own costs that hack into your profit margins.

A variety of medical billing and coding myths exist today as well that can cost your practice and result in patterns of risky behavior that can not only lead to denials but also audits and other negative consequences. It’s important to debunk common medical billing and coding myths, uncovering the truth behind them to improve the efficiency, productivity, and profitability of your practice. 

Here’s a closer look at some common myths and the real truth behind these misconceptions. 

Myth #1 – Modifier 24 Should be Used for All Services / Procedures in a Post-Op Period 

No, modifier 24 shouldn’t be used for all of the services or procedures that are provided during the global postoperative period. Modifier 24 is designed to be used along with the appropriate E/M code if E&M services or procedures occur during the post-op global period but are not related to the procedure that was done. Basically, it’s used to indicate that a provider is treating a patient for a new or separate problem. 

It’s important to remember that you cannot bill separately for any E&M services that are related to the original procedure during that post-operative global period. Avoid trying to add modifier 24 to these services because it will result in a denial. However, if non-related services are rendered to the patient, then you can use modifier 24 to ensure you go paid, even if they’re still in that global period. 

Myth #2 – Undercoding is Better Than Upcoding 

Upcoding refers to billing for services that weren’t performed or for services or procedures that are more complicated than those that were rendered. Sometimes this occurs if the physician provided the wrong data, a wrong code was entered, or there’s an attempt (which is illegal) to inflate a bill. Upcoding is illegal and can result in significant fines and, in some cases, criminal prosecution. 

However, don’t make the mistake of believing that undercoding is better or acceptable. Undercoding is also illegal and can bring with it fines and criminal prosecution, not to mention, it can result in a loss of revenue for your practice. Some practices have thought they should undercode to avoid audits or to reduce an individual’s superbill without realizing what the consequences could be. 

Myth #3 – If There’s No Code, It Can not Be Billed

Sometimes procedures or services don’t have a code assigned to them. However, this doesn’t mean that you cannot bill for that procedure or service. You can go ahead and bill for it using an unlisted code. The key is to make sure that you have complete, proper documentation to submit with that claim. Without documentation, you can expect this claim to be denied. But don’t leave money on the table and think that you cannot bill for it. 

Myth #4 – Modifier 22 Doesn’t Require Documentation

Modifier 22 is used when you need to indicate that a service or procedure required more work or time than usual. However, you cannot simply add modifier 22 without providing adequate documentation as to why the procedure or service required more work than it normally did. 

For example, perhaps a lesion was excised on the abdomen of an obese patient. The obesity ends up making the procedure more difficult and time consuming for you. In this case, you can use modifier 22 along with the code for the lesion removal to indicate that there was an increase in the complexity of this service. Just make sure there’s documentation to note why and how it was more complex to prevent a denial. 

Myth #5 – A Patient That is New to the Office is Always Considered a New Patient

This is a common myth that can quickly become an issue, particularly among large practices where there are multiple physicians in the same specialty. Even if the patient has never been seen in the office before, they may not be considered a new patient if they have been seen by one of the physicians on staff before in some way. 

For example, if a cardiologist goes into a hospital to see a new patient and then that patient comes into the practice the next week for follow up, that patient is not considered a new patient. Because they had seen the doctor within the past three years, that patient will be considered an established patient and you’ll need to use the established-patient code. Although billing as an established patient instead of using the new-patient code will cost you a few dollars, this will prevent a claim denial that is costly in both time and resources. 

Keep in mind, that established patient rules is applicable to all providers in the same specialty at a single practice. This means that if another cardiologist sees that patient after he encountered someone else from the practice in the hospital, once again you’re still required to bill with the established patient code. However, this rule doesn’t apply if the providers are in different specialties. If an orthopedic surgeon in the same group sees that patient that was seen by a cardiologist in the hospital, then you can bill for a new patient encounter. 

Myth #7 – You Don’t Need to Outsource Medical Billing and Coding

The truth is that it can be hard to find good in-house help, in-house medical billing services often require investments in IT dept, hardware, training, and other details can slip through the cracks and cost you, and errors easily occur because employees are left multi-tasking. As you hire more employees to help with on-site billing and coding, overhead cost increases. For these reasons, outsourcing medical billing and coding makes sense for many practices. You won’t need to train new employees, there’s no costs for hiring new employees, the company already has the right software, and their expertise of a quality company will generate more revenue for your practice. Outsourcing makes a lot of sense for practices of every size that want to improve efficiency and boost their bottom line. 

M-Scribe Medical Billing specializes in medical billing and coding, helping practices across the country booth both efficiency and revenue. Learn more about how outsourcing your billing and coding needs can benefit your practice by contacting us for more information at today. 


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