Avoid these 2 Common Medical Coding Mistakes At all Costs!

unbundling upcoding

You and your staff work hard to deliver your patients the best possible medical care. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. And to make matters worse, medical coding mistakes expose your practice to penalties ranging from thousands to millions of dollars. So read through this blog to learn the two most common medical coding mistakes and our other suggestions.

Medical Coding Mistake 1: Unbundling

Are you billing E/M codes for each patient visit to your medical office? It could lead to unbundling, and such reporting falls under the purview of fraudulent medical billing.  Unbundling is when you use different billing codes for components of a medical procedure when you are supposed to use a single comprehensive CPT code. As per existing medical billing guidelines, you cannot fragment a service into parts and code each component separately.

To avoid the medical coding mistake of unbundling, here is what you need to do:

  • When decision-making for the procedure or test is done on an office visit, don’t bill another E/M when the patient comes back for the test/ procedure. A very common example is a trigger point injection (TPI). A patient comes for a set of 3 trigger point injections as per the plan, the physician can’t bill these injections for an office visit unless the patient presents another problem.
  • Only bill one E/M visit when the same provider meets the patient multiple times on the same day.
  • Do not bill separately for an incidental procedure performed simultaneously as a complex one.
  • Refer to the list of mutually exclusive medical procedures defined by the Centers for Medicare and Medicaid (CMS). Do not perform mutually exclusive medical procedures on the same patient on the same service date.
  • Refrain from billing integral procedures separately. For instance, do not bill preoperative, intraoperative, and postoperative services separately.
  • Ensure that your medical coding staff refers to the latest version of the National Correct Coding Initiative (NCCI) edits published by CMS.

However, there can be exceptions to unbundling. For instance, you can bill twice for the same procedure within the 90 -days global period if the patient did not report the second issue when the first medical procedure was performed.

Medical Coding Mistake 2: Upcoding

Upcoding is when the provider chooses a code for a more complex diagnosis or procedure, which is more expensive than the actual procedure.

Here are some examples of upcoding:

  • Billing patients with a medical condition with the same E/M code rather than choosing a medical code depending on the severity of the medical condition.
  • Billing for more than the actual time spent with a patient.
  • Billing a telehealth patient for an office visit.
  • Using code for a complex procedure when a routine medical service was performed.
  • Using a modifier to indicate that additional services were provided when the standard medical billing code covers those services.
  • Billing for more expensive durable medical equipment (DME) than provided.

Some other suggestions:

  • Don’t stick to the same E/M always for your office, hospital, and facility billing; there is a range of codes that you must use.
  • Not all patients you see are level 5, even if you are a specialist.
  • Use the highest level of specificity of ICD 10 codes to support your E/M level.
  • Keep in mind some ICD 10 codes must be accompanied by a code first or a second code.
  • Make sure you are not using ICD 10 combinations that are not allowed.
  • Use current codes; the use of deleted ICD10 and CPT codes will prolong payments.

Whether intentional or unintentional, unbundling and upcoding can expose your medical practice to investigation and significant financial penalties. Read these examples of upcoding and unbundling multi-million dollar penalties shared by Phillips and Cohen ( an international law firm). In addition, the defaulting medical practice may be permanently excluded from participating in Medicare and Medicaid.

One way to ensure that you don’t inadvertently step onto an unbundling/ upcoding time bomb is to work with a professional medical coding and billing service with an established reputation in the industry.

PracticeForces has served U.S. providers, solo medical practices, and multi-practice group owners since 2003. Our goal is to turbocharge client practice revenues but to do it within the confines of CMS and HIPAA guidelines. If you need medical coding and billing assistance, we are just a phone call or email away. 

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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