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It's easy for a medical practice's billing and coding staff to be left out of the loop. Because they're not performing patient services, they rely on physicians and staff to inform them of what procedures occur during a visit. And sometimes, it's the simplest codes that are excluded the most.

MGMA recently interviewed Margie Vaught, CPC, about common medical coding errors that plague many practices. Vaught is a licensed instructor (PMCC) for the American Academy of Professional Coders and the coding content specialist for DecisionHealth. She's also a regular contributor to MGMA Connexion magazine's "Code of Conduct" column.

MGMA: How can a medical practice executive get physicians to care about coding?

Vaught: I think one of the best ways is to be able to show them what their numbers look like, and how when they're not involved in the coding, errors can be made, appeals have to be done and they're losing money every time they have to resubmit. Or that they're using so much staff time that they're losing on that end.

There are several really great articles that specialties and societies have written, encouraging surgeons and physicians to do their own coding, especially when it comes to surgical procedures. They are the actual provider and they're doing the case, so they know what's considered part of the surgery and what's considered a separate entity of that surgery. If you're just leaving that up to somebody [else] to abstract or select codes from that operative note, it can leave the door open for unbundling or not coding to the highest level.

MGMA: So it's definitely important that physicians should care about coding and that it's the medical practice administrator's job to get them on board.

Vaught: It is. Some of the terminology that surgeons and providers learn when they're going through medical school and residency is not always the same language that's in a CPT code. I've heard from many coders that they're looking for those wordings in the operative note, and if they don't see the wording that matches a CPT code, they infer that that procedure was not done, and therefore won't allow coding to take place.

For example, in a spine case [a coder] was looking for "laminectomy" and "framinotomy" and because they couldn't see them in the operative note, they thought it's not what the surgeon did, and would down code to say it was not performed. In reality if they read the note, it described the procedure of doing the work but it didn't say the words.

MGMA: What in your experience are the most common coding errors and how can they be avoided?


  1. One of the biggest ones that may seem obvious is forgetting your bilaterals. In an office setting (not surgical) I find that many times, for some reason, maybe the provider didn't circle that they gave an injection or medication on their encounter or superbill, whatever the office is using. So it goes without being billed.
  2. X-rays is another one. X-rays may have actually been performed during the service, but it didn't get documented on that encounter form and therefore now it didn't get billed. Same thing with labs. Those are some ancillary services that get left on the table.
  3. Supplies, giving our braces... those types of things are easily left off because of the flow of the office. Many times nobody's tracking those. We're not watching patients as they walk out to see if they have a new device on them [or] to see if they have a Band-Aid because they had labs drawn.

So sometimes all three get through the cracks and it's not until you look at the actual note - maybe months later if you're doing an internal audit - that you say, "Hey, wait a second, this patient had an injection and we didn't bill for it. Now we have to go back and send in the corrected claim and try to explain that well, we forgot to do this."


Read the next post, "Top billing and coding tips for any medical group practice," that concludes our interview with Vaught, or listen to our podcast with her. Then check out more of MGMA's expert coding tips and ideas. 


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