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Top Medical Coding Errors to Avoid in Internal Medicine Practice

March 13, 2018

Internal Medicine Medical Coding

Although many internal medicine practices are focusing on big coding changes, such as the ICD-10 transition, which makes coding a bit trickier, it’s important for practices to avoid losing focus on the coding basics. With so many new codes introduced and trickier coding, claim denials have increased for many practices. Keep your internal medicine practice in the black by avoiding the following common coding errors that can result in claim denials, costing your practice big time.

Choosing the Incorrect Procedure Code

With thousands of CPT codes, it is incredibly easy to accidentally choose the incorrect procedure code when completing claims. In many cases, it’s not confusion about the procedure that is the source of this common error. Inaccurate or incomplete code descriptions on electronic charge systems, cheat sheets, and encounter forms are often behind this common error. Forgetting to check out notes near the code or reading editorial comments at the beginning of a section within the CPT book can also result in this common error.

Using Modifiers Randomly

Modifiers are special two-digit codes that can be added to services to tell the payer about any special circumstances surrounding the procedure or service. HCPCS modifiers, which happen to be alphabetic or alphanumeric, are developed by CMS, and CPT modifiers, which are numeric, have been developed by the AMA. You can use both of these types of modifiers on HCPCS and CPT codes. However, it’s important to avoid using modifiers randomly. Incorrect information, desires to get claims paid off, or misunderstandings can result in randomly applied modifiers. Using modifiers correctly is not only essential for compliance, but also for revenue reasons within your internal medical practice.

Not Staying Up-to-Date

Failing to stay up-to-date on current coding rules and practices is essential, and failing to stay up-to-date can result in big coding errors that cost your internal medicine practice money. While your practice is understandably very cautious about your budget, ensuring that coders stay up to date is a wise investment. When coders are not up-to-date on current coding initiatives and rules, it has the potential to result in compliance risk and lost revenue for your practice.

Forgetting to Link to Diagnosis Codes

The HCPCS or CPT code used tells your payer about the service that your internal medicine practice performed. However, it’s the diagnosis code that lets the payer know why the service was performed. Since certain patients have multiple conditions that may require some unrelated services and other patients may require services only covered for specific conditions, it’s essential to make sure that codes for the visit to the office are linked to diagnosis codes.

Related Article: 3 Major Medical Coding Mistakes Providers Must Avoid

When a patient comes into your internal medicine practice to be seen for hypertension, and then they have a wart removed during that visit, the code for the actual visit would need to be linked to the hypertension diagnosis code, while the code for wart removal needs to be linked to the appropriate diagnosis code for warts. Otherwise, payers may not want to pay for the wart removal procedure if it’s linked to a hypertension code.

Failing to Read the Entire Chart Note

Simply reading the header of the chart notes is not enough to fully capture diagnostic and service information for a patient. While the documentation header may note an expected procedure, as the physician learns more about the patient during the office visit, the procedure may actually change. Reading the entire chart note on each patient will ensure the proper codes for both services and the diagnosis are used to prevent costly denials.

Preventing common coding errors can significantly improve revenue for your internal medicine practice. Staying up-to-date with new changes is one of the most important ways to avoid errors. Your practice may want to consider outsourcing your billing and coding needs. M-Scribe users certified medical coders who are up-to-date on current coding practices, which can help you reduce denials and increase practice revenue. Contact M-Scribe today at 770-666-0460 or email me at to learn more about how we can help your internal medicine practice with your medical billing and coding needs. 


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