Top Medical Coding & Billing Documentation Errors To Avoid

Even seemingly small documentation errors can lead to big problems in the medical billing process. This includes things like accidentally adding a digit to a recommended dosage to forgetting to input all of the patient’s pertinent contact information.

Not only can these things cause delays in your practice’s revenue stream, but they can also turn into a liability issue. Recurrent documentation errors can even get your practice red-flagged for an audit by insurance providers and medical industry oversight organizations.

Common Medical Documentation Errors

Experienced medical billing coders will point to some common medical billing errors. At the top of the list are prescribing errors, and transcription errors as well as administrative documentation errors.

Prescribing Errors

These are medication errors for prescriptions and other administered medications. They are rarely intentional, and even if the patient gets the correct dosage information, it can be a major issue if something as simple as a mistyped number can create major concerns in the medical billing process.

Transcription Errors

They differ slightly from prescribing errors as they are relative to a patient’s medication list. They are more common with patients who need to take or who are given multiple medications as part of their treatment strategy.

Administrative Documentation Errors

These often occur when the wrong documentation is accidentally entered in the actual drug dispensation of the patient’s medication list.

Common Causes Of Medical Coding Errors

When we take a closer look at medical billing, documentation, and coding errors, we find a few root causes to be mindful of. Most are related to simple human error, which can be more readily addressed with increased awareness. This includes:

• Incorrectly hearing prescription drug orders from oral instructions over the phone
• Dictation errors when listening to oral notes
• Accidentally entering the wrong medication after entering the first few letters
• Prescribing daily dosage for a medication that should be taken weekly
• Prescribing a weekly dosage for a medication that should be taken daily
• Difficult the read handwriting
• Documentation errors made by clinical staff
• Incorrect use of abbreviations
• Wrong copy-paste in the EHR
• Mis-entered lab results
• Using the wrong template
• Incorrect use of medical terminology
• Demographic errors
• Missing details about date and time
• Missing contact information for the patient
• Empty data fields
• A lack of automated intelligence software
• Lack of adequate staff training

How To Reduce The Risk Of Medical Billing Errors

Many medical billing services can be addressed or at least reduced by improved training for administrative staff. This includes making sure that clinicians and in-house administrative staff are given training or updated protocols for:

• Relevant medication legislation changes in the post COVID era.
• Providing them with knowledge of medications specific precautions, contraindications, and potential side effects.
• Putting in place cross-checking protocols for prescription orders.
• Cross-checking with a pharmacist before a specific medication is administered.
• Noting all known or unknown allergies or adverse drug reactions in a patient’s history.
• Clinicians and coders focusing on improved handwriting.
• Double-checking drug lists after the completing of documentation.
• Cross-checking the use of abbreviations

How Documentation Technology Can Help Reduce Medical Coding Errors

Physicians, clinical staff, and administrative staff need to embrace new technologies that encourage greater accuracy in medical coding and documentation. This will go a long way toward eliminating manual errors such as wrong dates, missing fields, and incorrectly entered the information. Many modern software systems have simple alert systems built into them that can flag errors and missing fields much like how modern-day word processing software helps catch spelling and grammar errors.

This includes things like CDSS or “Clinical Decision Support System” which provides clinical knowledge and related information about a patient in question. It then correctly selects and displays the pertinent information intuitively and at the appropriate time. This goes a long way toward spotting errors before they are entered into the system. It uses proof-based standards and guidelines with sophisticated protocols and procedures. This translates into recommendations as well as rules for care. This level of “Automated Intelligence” effectively analyzes medical records to spot missing information as well as improving accurate coding inputs.

When you compare the costs of support system technology to the cost and consequences of medical documentation errors, this type of system essentially pays for itself in short order. Not to mention it helps to prevent delays in the practice’s revenue stream for greater fiscal health.

Implementing Improved Organizational Strategies

Healthcare organizations need to work proactively to establish and promote an internal culture of safety and accuracy throughout every level of their medical practice.

The overarching goal is to ensure that all those in charge of documentation feel a sense of accountability, as well as an open willingness to ask questions, seek help from other knowledgeable staff, as well as highlighting potential issues that need improvement without fear of repercussions. This might also mean implementing peer support systems, as well as other things like work hour limits, counseling, and proactively engaging in feedback from concerned staffers at every level.

Creating an open forum for improvements throughout your small practice might take different forms. For some practices, a weekly meeting is the best forum for bringing up any necessary changes, whereas others might benefit from an online web portal to coordinate with the practice’s human resources department

The Benefits Of Outsourcing Medical Coding & Billing Practices

When you outsource your medical coding and medical billing services to a third-party vendor like Operant Billing Solutions, you are essentially getting a second pair of eyes. Our highly trained and experienced medical coding specialists have a keen eye for spotting a lot of the common documentation errors that cause delays in claim processes, payment, and revenue stream consistency.

We can correct simple errors, or make a quick inquiring to ensure that the information being submitted in the claim is 100% correct and easy for the payer organization to interpret correctly. Not only does this improve the overall accuracy of your claims and documentation, but it can also free up valuable man hours with your practice’s current in-house staff to handle other important tasks.