Is your urgent care coding team on top of its game? Or dropping the ball? One way to gauge their medical coding efficiency is accuracy. Let’s explore the three reasons this is a huge issue for urgent care clinics and how it affects everything they do.
What is the most important part of your urgent care? The patients and quality of care they receive. For the importance of patient care, accurate coding creates a valid record of patient care history. The physicians are required to list all conditions, diagnoses, and preconditions even if they’re untreated. When the patient care history is accurate, it can help the providers make better medical decisions for the patient leading to better patient outcomes. And relevant data can help providers develop ways to keep patients healthier—which is good for everyone.
There are multiple people involved in the healthcare payment process. For example, we go to the clinic, have a procedure done, the procedure then gets coded for the bill, the insurance company must review the bill and accept or deny it, the patient pays what is necessary, and finally, the facility is paid for the services. That seems easy enough, right? Not if the wrong codes are documented for the patient’s visit. If the payment process is inaccurate it can result in more work for the coders, the chart needing to be sent back to the physician, the patient paying too much, the insurance company paying too much, or the loss of essential revenue for you—the urgent care provider.
Denied! Rejected! Those are two things providers never want to see when trying to collect payment for services they’ve provided. The insurance company must know what services, tests, procedures, and medical devices were provided to patients. If this information seems to be out of place, the claim may be denied or rejected. Some common reasons that a claim would be denied due to coding errors would include upcoding, unbundling, double-billing, or coding oversight.
An example of upcoding would be if a patient comes in for a regular checkup that would be reimbursed at $50 according to the CPT code for check up, and the facility bills the patient for an extended checkup with a reimbursement of $75.
Unbundling would be when one code included two or more tests or procedures for a single rate, but rather than using that one code, each test/procedure is coded individually resulting in higher reimbursement.
Then there is double-billing. Double-billing is when the provider tries to charge multiple times for the same service. This could be using the individual code and a bundled code for the same service. The double-billing also includes when the provider is attempting to get paid by Medicare/Medicaid as well as a private insurance company or the patient for the same treatment.
An example of a coding oversight would be if a patient checks in at an urgent care facility with pain in his knee. The physician does an x-ray of the knee and the coder codes it as an x-ray of the wrist. The insurance fails to see why an x-ray of the wrist was done for knee pain and will deny the claim. The medical coder needs to make sure that the diagnosis and procedure codes fit together or it may result in a denied or rejected claim.
For seasoned coders, this may seem like a no-brainer, but with urgent cares opening every day, and new staff members responsible for coding medical encounters, it’s important to continually train staff to reduce the chance of lost revenue.
In the urgent care industry, financial success is closely tied to accurate medical coding and claim processing. Sometimes it makes sense to get help from outside the clinic to make sure you’re not leaving any revenue on the table. Our revenue cycle management and billing teams are always available to help you with information and services.