8 Signs You Should Invest In A Medical Coding Audit Before 2024

 All the change in healthcare over the recent years has unfortunately meant new opportunities for abuses of medical billing. This kind of fraud and misuse puts providers at risk financially and ultimately jeopardizes the quality of care you can provide in the long term. Many providers who have realized this understand that now is a good time to consider investing in medical coding audits. If you begin the process now, you can position yourself well in 2024 to be conducting audits that will provide considerable value to your organization. 

The American Medical Association’s Perspective
The American Medical Association (AMA) has stepped out recently to emphasize the importance of medical coding audits, paying particular attention to differentiating between “fraud” and “abuse” [1].

Medical coding and billing fraud is an intentional misrepresentation. Abuse on the other hand, is an innocent mistake, but still one that can’t be overlooked. This could be something unintentional like coding for a service that was more complex than what was performed because of a lack of understanding of a complex new coding system. 

Common Triggers for Medical Coding Audits
To help you evaluate how much value you can see from investing in a medical coding audit for 2024, here are some of the most common signs and symptoms that mean you should take action immediately and begin deciding whether this is something you can handle internally or whether outsourcing is a good choice for your situation.

Unbundling 
Also known as “fragmentation”, unbundling is a common issue in medical coding [2]. 

Both Medicare and Medicaid frequently have lower reimbursement rates when procedures are commonly performed together. This includes procedures like incisions and closures incidental to surgeries that should also be billed together. When these codes are billed separately, they can increase a provider’s profits through higher reimbursement from either agency. 

Upcoding
Upcoding is a rather straightforward issue and is simply when a provider uses codes that indicate more expensive services than were provided. An example would be medical coding reflecting a complex procedure when a more simple one was actually performed. 

A second type of upcoding involves time. It’s possible to upcode a bill for a visit by coding for more time than it actually involved. This happens with evaluation and management (E&M) codes – using one of these codes for a more time intensive and complex visit than a patient actually received. 

Another type of upcoding involves using modifier codes that indicate distinct additional services that weren’t provided during a visit when the services that were provided are actually covered by the standard code. 

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