Fraudulent billing, duplicate claims, and billing for medically unnecessary services constitute 46% of provider fraud cases.
(Health Payer Intelligence)
In physical therapy documentation, providers often face a dilemma: compromise patient care quality or create poor clinical Intentional or not, overcoding can be fatal to your practice.
Various legal and financial repercussions can ensue if overcoding and overbilling happens in your practice. Maury Regional Hospital, for instance, had to pay a substantial $1.7 million for overbilling in 2020.
To ensure your practice avoids the sanctions that can come your way, you must stay vigilant and avoid overcoding in the documentation process at all costs.
Here are nine common pitfalls of overcoding and how you can avoid them.
9 Common Pitfalls Of Overcoding And How To Avoid Them
1. Lack of Proper Documentation
Improper documentation is one of the most common causes of overcoding. This usually happens when patient data records aren’t updated on a regular basis, which leads to administering and billing for treatment services outside of what the patient needs. Often, improper physical therapy documentation can result in drastic long-term legal and medical repercussions.
How To Avoid Lack Of Proper Documentation
- Implement strict guidelines that enforce coding accuracy standards.
- Perform regular medical review sessions to evaluate clinical documentation quality.
- Audit billing claims before submitting them to payors.
2. Misunderstanding Or Misimplementing Coding Guidelines
Overcoding can also occur when CPT codes are improperly used, often due to misunderstanding coding guidelines. Other times, they may be misimplemented because of mistakes during data entry (e.g., CPT code 99214 is inputted instead of 99213). Keeping up with coding standards can be disorienting, with rules continually being added or updated.
How To Avoid Misinterpreting Coding Guidelines
- Conduct training sessions to refresh or educate your healthcare team on coding rules, regardless of an update.
- Distribute literature on coding guideline updates proactively to ensure providers are always in the loop.
- During training sessions, emphasize CPT codes with updated guidelines and ensure that your PT documentation complies with the updates.
3. Unbundling Services
Some therapy services are bundled to ensure patients undergo treatment plans for specific conditions. However, providers may bill bundled services as if they are separate. Even if accidental, payers may view this as a deliberate attempt to secure higher reimbursement rates.
How To Avoid Unbundling Services
- Familiarize yourself with the codes for bundled services.
- Keep track of past instances when bundled services have been mistakenly unbundled for future reference.
- Stay informed of updates on coding guidelines related to bundled services.
4. Upcoding Services / Inappropriate Use of Modifier Codes
Upcoding is often perceived as deliberate, as it involves misrepresenting the actual length and level of service, leading to higher reimbursement. It is also a medical record documentation challenge, especially regarding modifier codes. Due to continual updates and guideline changes, providers may use inappropriate modifiers for specific scenarios. Regardless, this can also be seen as deliberate, resulting in claim denials or legal sanctions.
How To Avoid Upcoding Services
- Enforce strict protocols restricting and sanctioning instances of upcoding.
- Include modifier codes as an essential component of documentation training.
- Provide resources on modifier codes to keep providers adequately informed.
5. Duplicate Claims
Duplicate claims typically occur due to note cloning for physical therapists to save time on medical documentation. Other times, they happen because the provider cannot track services that have already been billed. Besides the risk of getting tagged for cloning, though duplicate claims may incur little risk of sanctions, they consume a hefty amount of time and energy to correct for proper reimbursement.
How To Avoid Duplicate Claims
- Implement guidelines and best practices around note cloning.
- Prioritize record integrity and consistency during quality checks, as well as spot and evaluate repeated information.
- Use an AI tool like ScribePT to streamline patient documentation without the risk of getting tagged for cloning.
6. Billing for Non-Covered Services
Billing for services not covered by the patient’s insurer can happen occasionally, though this is usually unintentional. Nevertheless, it is considered misbilling and should be avoided.
How To Avoid Billing For Non-Covered Services
- Ensure you’re billing for services actually rendered throughout the patient’s engagement with your clinic.
- Review patient histories regularly to ensure your coding is accurate.
- Actively verify patient insurance coverage prior to the appointment to ensure your services are covered by the patient’s insurance provider.
7. Patient Information Errors
Patients entrust you with their sensitive information during their engagement with your clinic, so your objective is to ensure its accuracy and protection. Unfortunately, information errors can still occur with the patient’s demographics or insurance details. This poses risks not only to your billing and coding workflow but also to the patient experience.
How To Avoid Errors In Patient Information
- Verify the information at every patient visit to ensure maximum accuracy.
- Use the patient’s history to corroborate your information.
- Consider using an AI-powered documentation tool like ScribePT to record and transcribe vital details during the patient encounter.
8. Overlooking Compliance with Payer Requirements
With payer requirements constantly changing, it can be tempting to overlook them to get documentation and billing over with. Nevertheless, this only leads to further issues down the line, especially with claim reimbursements.
How To Avoid Mistakes With Payer Requirements
- Constantly keep track of payer requirements and their updates.
- Distribute literature on requirements and updates to ensure your healthcare team stays abreast.
- Contact payers directly via call or email to get the most updated information.
9. Inadequate Training and Managerial Support
According to a 2024 Medscape survey, 62% of respondents say that bureaucratic tasks are the main cause of their burnout. Providers must stay up-to-date with coding guidelines and standards, or they may receive legal sanctions that consume a lot of resources. Without ample training and support from management, providers may experience burnout, be more likely to engage in overcoding, and even have a hard time upholding patient care standards.
How To Avoid Having Insufficient Training And Support
- Provide regular training that educates staff on billing, coding practices, and updates.
- Hold regular forums, 1-on-1 sessions, and other team-building activities where providers can reduce stress and express their concerns.
- Integrate AI scribe tools like ScribePT to streamline documentation for physical therapy.
Coding Integrity Is Practice Integrity
Avoiding overcoding at all costs ensures the integrity and credibility of your practice. Safeguard your documentation workflow with an AI scribe tool that takes care of note-taking while you focus on engaging your patient directly.
ScribePT is the best AI scribe for patient documentation. Discover how ScribePT can transform how you create SOAP notes for physical therapy while allowing you to enjoy doing what you do best: patient care.
