TOP CODING MISTAKES IN 2025

The world of Medical Coding has grown exponentially over the past ten years, and with that, so have coding errors, unfortunately. Just read a recent Comprehensive Error Rate Testing (CERT) Report from CMS for your state or the country, and it is self-explanatory. CMS created the CERT program to measure the error rate of improper Fee-for-Service payments, and they have found many FFS errors over the past ten years. The error rate measures payments that didn’t meet Medicare requirements; it doesn’t indicate fraud necessarily, but it is fairly reflective of Coding errors. Medical coding errors represent a significant challenge for the healthcare industry, with approximately 50% of Medicare claims being inaccurately processed. Even minor mistakes can lead to substantial consequences, including claim denials and reduced reimbursements. If these inaccuracies persist, they can result in revenue loss, which is essential for the industry’s growth and sustainability.

Medical coding errors can generally be classified into two categories: “fraud” and “abuse.” Fraud involves intentional misrepresentation, while abuse refers to innocent mistakes that are nonetheless significant. According to the current publication of the AMA’s Principles of CPT® Coding, an example of abuse might occur when a service is coded as more complex than what was performed due to a misunderstanding of the coding system.

COMMON MISTAKES IN MEDICAL CODING

INADEQUATE DOCUMENTATION: The medical record lacks clear, detailed, and accurate information. Insufficient or unclear documentation hinders the assignment of precise codes. Inaccurate documentation can result in underbilling, claim denials, or legal complications. Proper documentation is vital for accurate coding. Common coding errors include incorrect patient information, missing physician signatures, and insufficient details on procedures performed. Therefore, the implementation of electronic health records and regular audits is crucial for ensuring correct documentation.

UNBUNDLING: Unbundling of codes occurs when separate CPT codes are used for each component of a procedure instead of using a single code that encompasses the entire procedure. This practice should be avoided unless it is necessary for accurate coding. Unbundling may result from misinterpretation or deliberate actions aimed at inflating payment claims.

UPCODING: Example: As a physician specializing in oncology, you often encounter patients with highly complex conditions. Consequently, you may be inclined to report the highest-level evaluation-and-management (E/M) service regardless of the actual condition presented by the patient. However, it is crucial to accurately report the appropriate level of E/M code based on the patient’s specific condition rather than solely relying on your specialty’s complexity.

There are instances of fraud related to upcoding. For example, a psychiatrist was fined $400,000 and permanently excluded from participating in Medicare and Medicaid due to upcoding practices. He billed for 30- or 60-minute face-to-face sessions with patients, while meeting with them for only 15 minutes for medication checks.

NCCI EDITS: Neglecting to review National Correct Coding Initiative (NCCI) edits when submitting multiple codes is a common error. The Centers for Medicare & Medicaid Services established the NCCI to ensure that proper coding practices are adhered to and to prevent improper payments for Medicare Part B claims.

Automated prepayment edits are determined by analyzing each pair of codes billed for the same patient on the same service date by the same provider to ascertain if an edit exists within the National Correct Coding Initiative (NCCI). According to the AMA’s guidelines, if an NCCI edit is identified, one of the codes will be denied. NCCI edits typically include a list of available CPT modifiers that may be utilized to override the denial. However, in certain instances, explicit instructions indicate that no modifier can be used to override the denial.

MISMATCHED DIAGNOSIS AND PROCEDURE CODES: The diagnosis code must correspond accurately with the procedure performed. During the coding process, each procedure code (CPT or HCPCS) must be supported by an appropriate diagnosis code (ICD-10). The purpose of the diagnosis code is to verify that the correct diagnosis was utilized to reach the medical conclusion and to justify the recommended procedure. Failure to substantiate the diagnosis and the procedure may result in claim denials.

INCORRECT MODIFIERS: Using the wrong modifier or omitting a required modifier. Healthcare providers may use incorrect modifiers when billing for procedures. A medical modifier, a two-character code, provides extra details about a procedure or diagnosis and is crucial for accurate billing. Incorrect modifiers can lead to wrong reimbursements or claim rejections. Common coding mistakes include using mismatched modifiers, omitting modifiers, or applying multiple modifiers that cause claim rejections.

ADDITIONAL FACTORS THAT LEAD TO REVENUE LOSS:

INCORRECT PATIENT INFORMATION: Errors in patient information can result in claim denials. Instances of incorrect patient information verification have resulted in coding errors. These errors may involve using inaccurate insurance IDs, failing to confirm coverage or medications, or submitting claims to the incorrect insurance provider. Therefore, front desk staff need to be trained in accurately verifying patient insurance information before submitting documentation to prevent these medical coding errors.

INADEQUATE VERIFICATION OF INSURANCE COVERAGE: Ensuring the verification of insurance coverage, including any updates, is crucial to avoid claim denials. Patient eligibility verification is a critical part of the healthcare revenue cycle. It can help prevent errors with claim submissions, reduce denials, boost the bottom line, and help patients understand what their insurance will cover.

TIMELY FILING LIMITS: It is imperative to ensure that claims are submitted within the designated timeframe to prevent any delays. Stay informed about payer-specific deadlines, as different insurance companies have varying filing deadlines. Regularly review and maintain a comprehensive list of timeframes for the various payers you serve. Additionally, be aware of exceptions to these deadlines, such as situations involving retroactive insurance eligibility or errors made by payers.

To remain competitive, medical coding teams should monitor key performance metrics such as MGMA:

MGMA Benchmarks for Medical Coding in 2025

Coding Accuracy Rate >95%
Claim Denial Rate <10%
Days in Accounts Receivable (AR) <30 days

ZENMED Solutions, INC., adheres to performance metrics to ensure compliance across the healthcare landscape for its clients. Non-compliance can result in significant consequences. With increased funding for healthcare fraud detection, agencies such as the OIG and state Medicaid Fraud Control Units are enhancing their activities. Non-compliance may lead to financial penalties and legal actions.

Partnering with a reputable billing company such as ZENMED SOLUTIONS, INC. can enhance your Compliance Program, along with your Revenue Cycle Management (RCM) processes through our advanced AI software, BLISS.

ZENMED Solutions, INC., has developed an RCM tool named BLISS – “Barometric Live Intuitive Solution(S).” This intuitive tool can track, categorize, strategize, correct, and learn (TCSCL) the specifics of any practice in real-time, thereby improving all aspects of RCM. We specialize in automating back-office tasks within the healthcare industry. The team at ZENMED Solutions Inc. understands the challenges a practice faces when trying to submit clean claims, which directly impacts the coding and billing departments. Our teams are available to assist with these challenges as needed.

Some of these processes BLISS can assist with include the following:

Correct Procedure code(s)/CPT
Correct Diagnosis code(s)/ CD 10CM /ICD 10PCS
Correct HCPCS codes
Correct Modifier(s)
Keeping abreast of Payer Reimbursement policies and LCD/NCDs for CMS
Date of denial/rejection, if a denial is received, as the payer only allows a certain amount of time to appeal
Description of Denial / Rejection Code(s)- coding error, patient registration error, precertification
Remittance identification number
Charge capture, a crucial step in the revenue cycle.
Automating and tracking claims submissions

Establish a “Culture of Compliance” by prioritizing compliance within the practice’s core principles through well-defined policies, procedures, and leadership support. This approach ensures the protection and integrity of your practice, in other words, “Bulletproof Your Practice”!

“A little knowledge that acts is worth infinitely more than much knowledge that is idle.” Khalil Gibran

ZENMED SOLUTIONS, INC., is based out of Diamond Bar, California and we have over 75 clients around the U.S. If you are tired of sleepless nights worrying about revenue bleeding out of your practice, we can help, take the first step and call us at (844)-307-0806, or email us at: Info@ZenMedInc.com.

Happy Coding!

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About
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Holly Cassano

CPC, CRC, AAPC Certified
MBR AAPC/NAMAS
Director of Compliance and Education, ZENMED Solutions INC.

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