Often in medical coding and billing , mistakes happens but if they are not addressed immediately or if they are overlooked, it could turn into a costly affair for the provider causing potential loss in revenue. In this series of coding and billing errors, we will try to highlight some of such common errors and their financial impact on the practice.
A physician performed an arthrocentesis on the acromioclavicular joint bilaterally on a 74 year old female. The biller billed the CPT code 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst ) without the modifier-50. The insurer processed the claim and paid for unilateral service (100%) instead of bilateral service (150%).
Medicare allowable for the procedure is $52.41 for unilateral service and $78.61 for bilateral services. In this case,a potential loss of $26.20 for the physician and this could add up if there are multiple cases like this.
An ophthalmologist performed excision of a pterygium with graft on a patient but failed to document this in the chart. The staff didn’t know and used the CPT code 65420 (excision or transposition of a petrygium without a graft) in place of CPT code 65426 (excision or transposition of a petrygium with graft).
The difference in the allowable between these codes per Medicare is $117.70. This loss could have been stopped, had the physician documented in the chart that petrygium was done with a graft or if the staff had questioned the physician about the procedure.
A Chiropractor provided spinal manipulation on a medicare patient and coded CPT 98940 (1-2 body area) but forgot to put in modifer-AT on the superbill. The billing staff overlooked and submitted the claim without this modifier. Medicare denied the claim stating maintenance therapy.
Financial Impact: The physician lost $25.67 which is the allowable amount for this procedure code. This figure can add up significantly if the chiropractor sees more such patients in a day.