Roni Berlin is an associate vice president of Revenue Integrity at ExdionRCM Solutions.For more information visit 

Roni Berlin

A physician’s workday is often segmented into two major jobs: Seeing patients and performing the necessary administrative duties to ensure they are paid for work they have performed.

Burnout is always a significant risk in any medical practice. It’s mostly caused by doctors and other clinicians having to see too many patients in too little time. Their levels of stress and exhaustion are further compounded by dealing with an enormous number of complex but monotonous administrative tasks at the end of the clinical workday.

As a result, by the time most physicians check off all the tasks on their daily clinical and administrative worklists, they just want to go home and get enough rest to be able to tackle the next day’s work.

However, the brutal workloads and the disparate skills required to complete the daily grind of practicing medicine and getting paid for it means many physicians are not wholly engaged in ensuring their practices are run optimally. If your goal is to survive to get to the next day, you are not going to perform a deep dive into how your practice is operating and whether it is the best possible approach.

As a result, medical practices throughout the U.S. systematically engage in suboptimal medical coding for their patient encounters. And as there is no fixed way to code an encounter, it means that task can be performed in a myriad of ways. Add to that the fact commercial insurance and Medicare auditors are always poring over claims data and may demand a payment clawback, and many doctors will they resort to the coding approach they believe is least likely to draw any attention. It may be the safest path, but it is not the most accurate representation of the care provided. In the aggregate, these errors and omissions can lead to a sizable revenue hit for medical practices.

However, out of this chaos emerges patterns, particularly in terms of the most costly coding errors for a medical practice. Among them are:

Inappropriate Coding For Evaluation and Management Services (E/M)

Issues with coding for E/M is often linked to the hectic schedules of physicians and other clinicians, who may see 20 or more patients a day. As a result, the approach often goes in one of two directions: Overly aggressive without proper documentation to back it up, which may trigger an audit; or too low for the documentation provided, which leaves money on the table. And missing E/M codes can make the problem even worse.

This is often the result of incomplete charting, which again is often due to provider distraction. Many times, these charts remain without follow up and the claim is being sent out late or not billed out at all.

While typically a front desk issue, the confusion between whether a patient is new or established can lead to lower payments if not properly resolved.

Providers often miss administrative procedure codes for minor treatments, which can leave money on the table. That includes codes for injections, immunization and immobilization. Giving patients an injection is among the most routine services provided in a primary care or urgent care practice. But one shot includes two codes: a CPT code for the injection, and a separate code for the medication or vaccination that is being provided. Modifier 25 may also be applied if other care is being rendered. A similar oversight can occur when putting a splint on a limb. There is a code for the application, and a separate code for the supply item, whether a splint, cast or other device. Using a single code leaves money on the table.

Among the biggest errors coding are how modifiers 25 and 59 are deployed.Either modifier can expand treatment and payments considerably. However, using them appropriately can be tricky, and mistakes can lead to audits and clawbacks. Modifier 25 may be used in conjunction with an E/M encounter when a particular service that is performed – such as an injection – is separately identifiable. The use of modifier 59 is appropriate only in slightly different circumstances to identify procedures other than E/M services that would not normally be reported with such an encounter.

This is not a complete list of the coding errors a physician or their practice can make, but it covers some of the most obvious ones. Using an outside firm that can perform an analysis of your practice’s approach to coding and propose solutions is a potential way to address this issue.

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