One of the biggest billing mistakes urgent care providers can make is coding patient visits incorrectly in the EMR. Not only does this create an inaccurate record of the care they provided, but it can result in lost revenue and, in some cases, legal liability. That’s why it’s so important for your urgent care center to have a quality assurance program in place to ensure providers are educated (and continually re-educated) on how to use your EMR correctly)

Providers Pay Settlement after Coding Incorrectly

Just a few weeks ago, the U.S. Attorney’s Office for Maryland announced that providers at Baltimore-based St. Agnes Health System will have to pay a combined $943,767.48 to settle allegations that they reported venous sufficiency studies incorrectly.

The providers administered tests to patients to assess the venous sufficiency in the lower extremities, including a venous Doppler duplex, in order to determine if there was blood flow issues in the patients’ legs. The providers billed Medicare under CPT 93970 (Duplex scan of extremity veins, including responses to compression and other maneuvers; complete bilateral study). However, billing records showed that the providers also billed for an additional test using CPT 93965, which references an older, different technology that has been replaced by CPT 93970.

According to “Part B News,” CPT 93965 (noninvasive physiologic studies of extremity veins, complete bilateral study [e.g. Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmograph]) was deleted at the end of 2016. When CPT 93965 as in use, Medicare paid $122 per test. The fee for CPT 93970 in 2016 was $200.

The Importance of a Quality Assurance Program

It’s easy to see how providers could get these codes confused. As Julia Kyles from “Part B News notes, “the [code] descriptors are similar and there were no bundling edits to stop practices from reporting both services for the same patient on the same day.”

According to Monica Klosa, chief operating officer of PV Billing, depending on how the urgent care’s EMR works, urgent care coding errors like this are often a result of the provider using the EMR incorrectly.

“If the provider, for example, documents a procedure in the wrong section of the EMR, it could result in the EMR not being able to pick up on that documentation, resulting in lost revenue,” says Klosa.

Klosa says it’s also important to look at whether providers are over-documenting, which can inflate the codes, or under-documenting, which can result in under-coding. Both scenarios can cause problems for providers.

The providers in this case were very fortunate. They did not have to admit guilt or go through the time and expense of a trial. But this is still a good warning to urgent care providers to remain vigilant when it comes to coding patient visits. Working very closely with your chief medical officer, officer manager, billing staff and coding staff to develop a quality assurance program centered on CPT code and EMR use education will help prevent urgent care coding errors like this from happening. Once your quality assurance program is in place, make sure you perform regular audits on every provider in the practice to ensure they are following best practices at all times.

When it comes to coding patient visits, there’s simply no room for error.

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