ED Coding and Reimbursement Alert

Question: Within the past few months, on two occasions my billing department submitted claims through insurance companies for two procedures using the wrong codes. The procedures actually should have been billed using a higher RVU code since both cases were complicated and another code better described the procedure. I have already been paid on both claims. Should I just let this go, or is it acceptable practice to resubmit the billing for these procedures with the proper code and return the fees from the original bill?

Maryland Subscriber

Answer:  You should rebill using the proper codes. Mistakes happen and you need to bill correctly. You can send a corrected claim with a short letter explaining that the new submission is not a duplicate, but corrected coding and billing.

Consequences: If you get audited, you could be fined for undercoding as well as overcoding. During an audit, undercoding and upcoding can both be deemed fraudulent billing, so it is always important to correct errors.

Best bet: Send documentation to support these corrected codes so that the carrier will pay the new claim correctly and timely. Depending on your carrier, you may have to return the entire original reimbursed amount back to the carrier for reprocessing for the additional payment. Other payers will just send you the difference.

Suggestion: You may also want to call the patient and simply explain what happened so that if the patient receives additional communications about the surgery from his payer, he won’t think your ED is trying to charge twice.

Inform the patient that you are sending a corrected claim to the insurance carrier and that they should be expecting an extra explanation of benefits (EOB) from the insurance company showing that they reprocessed the claim using the correct procedure codes.