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Are billing and coding issues impacting your bottom line?


With a recent report published by the U.S. Department of Health & Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS), CMS projected nearly $145 million in overpayment for oncology patients in their year July 2020 through July 2021. Most of those overpayments were noted to be from insufficient documentation and improper coding.

While the total number may not be as high for specialty patients, the same issues around documentation and insufficient coding will impact your practices as well.

What does that mean for your practice?
Community practices must be aware that incorrect coding and documentation could put them at financial risk. If CMS audits your practice, how accurate would they find your billing and documentation? With the ever-changing landscape in healthcare, it’s challenging to stay on top of nuances. Every year we see changes to CPT, HCPCS, and diagnosis codes. Are you up to date on the changes for 2023?

Add to that, your commercial payers probably require different documentation depending on the plan, state, and/or diagnosis.

When a code is changed (possibly annually), are you prepared to run all new prior authorizations?

Some tips to stay on top of the changes:

  • Run reports on the codes that have been changed, added, or deleted. Track the reimbursement you receive on the changed/new codes, to be sure you are being paid appropriately. Ensure you are no longer billing the codes that have been deleted.
  • Run a current denials report to track trends. Are you seeing increased denials on a particular code? Are you seeing increased denials from a particular payer? Is this a billing/coding issue or is this a payer with extra hassle factors that you don’t see with your other payers?
  • Don’t fall behind on looking at this report – it means revenue for your practice.
  • Look at the rates of reimbursements for your top 10 payers. Have they changed since last year – and you are receiving a lower payment? It’s possible the payer has changed rates, and you have not updated your contracts.
  • Look at the timing on reimbursements. Are your reimbursements taking longer? If so, why is it taking longer? If there is not a billing error, the insurance company may owe you interest on delayed payments.
  • Work with your billing software and EMR vendors to ensure added, changed, and deleted codes have been updated appropriately to include the updating of fees and fee schedules.
  • If your practice is using InfoDive® for reports, work with your business coach to identify denials as well as plans that are reimbursing below Medicare rates.

Understanding your business processes around coding and documentation will help you address any audit of your practice.

Our business optimization consulting team has expertise in helping practices with improving their processes around coding and reimbursement strategies to protect their bottom line. Reach out to Amie Koenig or John Dodd at if you have questions or need insights into how they could help you.