Do not fall into the trap of downcoding just to be ‘on the safe side.’ As a physician, it is your responsibility to code based on your documentation. If you continue to downcode, you’re not only at risk of losing thousands of dollars in revenue per year, but you’re also potentially triggering an audit of your practice.  

Triggering an Audit

One of the main reasons why practices undercode is to avoid triggering an audit. It is important to remember that claim reviewers study ‘bell curves’ to determine when a practice is coding outside the norm. Reviewers do not just look for upcoding, but for all trends across the board! For example, most practices see patients with complex diagnoses that require high level E/Ms at least once in a while. So, if an auditor is reviewing your records, it will certainly look suspicious if there aren’t any higher level codes being billed. Do not create suspicion by deliberately downcoding claims; check documentation in the patients’ medical records and bill accordingly.

Losing Revenue

In order to get proper reimbursement, you must thoroughly and accurately document your patient medical records. It may not be a significant difference between billing a level four new patient office visit (99204) and a level three new patient office visit (99203), but when that difference is multiplied to every single miscoded claim over the course of a fiscal year, your practice may be out thousands upon thousands of dollars. If you document properly, you are entitled to bill for the service provided. Do not let revenue go uncollected!

If you have any questions or concerns about your billing and coding, please call at 248-932-2607 to set up a comprehensive evaluation of your practice.

By Scott Shatzman