Adhering to billing guidelines can be a frustrating and challenging task. Despite painstakingly trying to do so, physicians often nonetheless find themselves facing denied claims and post-payment recoupments.

According to a coding guide published in August 2022 Volume 8, Issue 99 of the Medical Economics Journal, concentrating on coding and documentation compliance might help physicians to avoid medical claim denials and increase their odds of getting paid.

One common impetus for claim denials is due to a simple error—incorrect patient status listed on a document. Victoria Moll, CPC, owner and founder of Pennsylvania-based Contempo Coding, LLC, notes that physicians should not assume that a patient who is new to them is new to the entire practice. For instance, that patient may have had a telehealth appointment the prior year with another doctor at the practice, which would actually deem them to be an established patient. If physicians want to get paid, they should not make assumptions regarding a patient’s status. Moll also points out that unspecified diagnosis codes can lead to claim denials.

Physicians Must Stay Current With the Latest Coding Changes

Based on the coding guide, office visit evaluation and management (E/M) codes coupled with incorrect application of prolonged service codes may also lead to claim denials. If physicians want to get paid, they need to be aware of the most updated rules. According to Kim Huey, MJ, CHC, CPC, CCS-P, PCS, SPCP, owner of Alabama-based KGG Coding and Reimbursement Consulting , LLC, physicians must stay current with the latest coding changes to get paid. They would also benefit from knowing when to use a singular combination code versus multiple diagnosis codes.

Not only do physicians need to know the right codes, but they also should know when to report prolonged services. Toni Elhoms, CCS, CPC, CEO of Florida-based Alpha Coding Experts, LLC, notes that physicians must make it a point to document the total face-to-face and virtual time spent with a patient on any specific date, making sure to also document the reason for any additional time spent on the patient’s healthcare. Furthermore, Elhoms encourages physicians to ensure that they’re documentation supports incident-to-billing criteria. If not, they could face denials due to errors like billing incident-to-services for a new patient or billing incident-to for an established patient although the plan of care has been altered.

Invalid medical codes lead to medical claim denials. Tammy Tipton of Oklahoma City-based owner of Appeal Solutions, Inc., stresses the importance of leveraging front desk staff in order to get paid for medical claims. By ensuring that they are current on verification of benefits, policy language, and precertification, physicians are maximizing the chances of avoiding denials. For instance, Huey notes that knowledgeable front desk staff can determine whether Medicare should be reported primary or secondary for a particular patient.