When submitting claims to Medicare for processing, ensure the codes on the claim match the documentation that is in the medical record. A common error is billing for the wrong date of service or using an incorrect code.
Issues that lead to incorrect ICD-CM, HCPCS, CPT, or modifier coding include incomplete notes, care was provided but not documented, missing test results, documentation not completed timely, illegible documentation, and inconsistent documentation.
Below are some tips to prevent this error:
- Make sure the date(s) of service are documented
- Ensure the proper principle diagnosis and principle procedure are coded correctly
- Include all documentation to support the codes billed
- Use a checklist to ensure all of the essential pieces are included in the record
- Make sure that both sides of double sided documents are submitted
Remember that it is the billing provider's responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation.