On the surface, medical coding seems simple enough. Assign a specific code to a medical diagnosis, treatment, symptom, drug reaction, or procedure. But, when you start digging into the details of how medical coding works and what it can affect, the liability potential of applying the wrong medical codes becomes apparent.
Mismatched Coding Can Lead to Insurance Fraud Claims
This is not a sensationalist headline. It is actual reality.
Let's say a medical coder mismatches certain procedures and diagnostic codes on a patient record. The problem is not detected before being sent to the insurance company. The insurer reviews the claim and denies it due to lack of medical necessity (the treatment does not match the diagnosis). If this is only one …show more content…
Too many denied claims, based on mismatched coding, will raise the attention of the payers. This can trigger further scrutiny for past, current, and future claims. If the insurance company finds a pattern of mismatched codes, they have the right to take legal action for potential insurance fraud. And, even worse, if the practice accepts Medicare or Medicaid, this can trigger government scrutiny.
Downcoding Is a Sign of Potential Fraud
Downcoding involves assigning a medical diagnosis, treatment, or symptom using a generic classification instead of using the appropriately detailed one.
For example, with the implementation of ICD-10, medical codes now have 7 characters. All seven characters are required to classify any item on the patient record in appropriate detail. It is possible, however, for the coder to only use the first three to six characters instead of the full seven. This is a more generalized code that does not have the detail of the full seven characters. This is known as downcoding.
Medicare can and will deny claims that do not have the full codes applied appropriately. If a particular provider has a pattern of downcoding too many claims, it is seen as a sign of potential fraud and may trigger an audit or other kind of scrutiny.
It is Too Easy to Introduce
Mismatched Coding Can Lead to Insurance Fraud Claims
This is not a sensationalist headline. It is actual reality.
Let's say a medical coder mismatches certain procedures and diagnostic codes on a patient record. The problem is not detected before being sent to the insurance company. The insurer reviews the claim and denies it due to lack of medical necessity (the treatment does not match the diagnosis). If this is only one …show more content…
Too many denied claims, based on mismatched coding, will raise the attention of the payers. This can trigger further scrutiny for past, current, and future claims. If the insurance company finds a pattern of mismatched codes, they have the right to take legal action for potential insurance fraud. And, even worse, if the practice accepts Medicare or Medicaid, this can trigger government scrutiny.
Downcoding Is a Sign of Potential Fraud
Downcoding involves assigning a medical diagnosis, treatment, or symptom using a generic classification instead of using the appropriately detailed one.
For example, with the implementation of ICD-10, medical codes now have 7 characters. All seven characters are required to classify any item on the patient record in appropriate detail. It is possible, however, for the coder to only use the first three to six characters instead of the full seven. This is a more generalized code that does not have the detail of the full seven characters. This is known as downcoding.
Medicare can and will deny claims that do not have the full codes applied appropriately. If a particular provider has a pattern of downcoding too many claims, it is seen as a sign of potential fraud and may trigger an audit or other kind of scrutiny.
It is Too Easy to Introduce