1. Unbundling Codes

When a single code exists to cover all parts of a procedure, it should be used. Unbundling occurs when multiple Current Procedural Terminology (CPT) codes are used separately instead, either due to misunderstanding or to increase payment. This practice can lead to audits and penalties.

2. Upcoding

Upcoding happens when a provider reports a higher-level evaluation-and-management (E/M) service than what was actually performed.

Example: An oncologist who consistently bills for the most complex patient visits, regardless of the patient's condition, may be flagged for upcoding.

In some cases, upcoding is outright fraud. A psychiatrist was fined $400,000 and permanently excluded from Medicare and Medicaid after billing for 30- to 60-minute sessions when he actually saw patients for only 15 minutes.

3. Ignoring National Correct Coding Initiative (NCCI) Edits

The Centers for Medicare & Medicaid Services (CMS) developed the NCCI to prevent incorrect coding and inappropriate payments. These automated edits analyze all billed codes for a patient on the same service date and deny incorrect pairings.

Example: If a provider bills separately for a lesion excision and skin repair, but CPT guidelines include simple repairs within the excision codes, this would trigger an NCCI edit. However, if the repair was done at a different site, the provider should append a modifier to indicate that the procedures were separate.

4. Incorrect Use of Modifiers

Modifiers clarify services rendered, but using them incorrectly can result in claim denials. Examples include:

• Modifier 50 (Bilateral Procedure): Applying it to a code that already includes bilateral service.
• Modifier 22 (Increased Procedural Services): This should only be used when extensive documentation supports the need for additional work.

5. Errors in Reporting Infusion and Hydration Codes

Infusion and hydration codes are time-based, so documenting start and stop times is essential. Additionally, if services span two days, they must be coded correctly.

Example: If continuous intravenous hydration runs from 11 p.m. to 2 a.m., it should be reported separately as initial (96374) and sequential (96376) administrations, rather than as a continuous infusion.

6. Improper Reporting of Injection Codes

Only one code should be reported for the entire injection session rather than coding multiple units of a single code.

7. Reporting Unlisted Codes Without Documentation

When an unlisted code is necessary, detailed documentation must accompany the claim. Failing to do so can lead to claim denials and payment delays.