Coding and Billing Issues in Healthcare

The country’s medical system is well debugged nowadays and is at a high level; however, errors are present for various reasons. Mistakes are made because of the human factor; in other words, employees’ manual actions when filling out data. Mistakes lead to a deterioration in the US healthcare system’s reputation and customers’ and payers’ dissatisfaction. Medical problems relate to billing and coding and arise from lack of data, upcoding, telemedicine coding errors, and missing or incorrect information.

To receive insurance payment, medical professionals must provide the required data to the insurance service. If insufficient data is provided, the request may be postponed or rejected. For example, a billing officer might make a mistake and not link required data, such as procedural and diagnostic code. Another example would be the incorrect information provided by the doctor, which directs to the same consequences. When transferring documents, strict procedures are required since delivering correct data in full will reduce employees’ efforts and save time.

Upcoding occurs when a billing officer accidentally or deliberately confuses codes to bill a more expensive invoice. It rarely concerns the patient since most of the costs are covered by insurance. However, “cost overruns leave a negative imprint on the entire health care system” (Grant-Kels et al., 2016, p. 149). For example, a nurse performed a procedure, and the code shows that a doctor completed it, which is much more expensive. Upcoding is a severe offense, as it can force a patient to pay for services that were not done and undermine the entire health care system’s reputation.

Telemedicine markedly simplifies the doctor’s work and communication but complicates billing. It implies a supplementary coding system, although the system does not differentiate between local services and telemedicine. (Demaerschalk et al., 2017). For example, the GT modifier is used for real-time communication, and the GQ modifier is used asynchronously, sending emails or x-ray pictures. Billing errors lead to payment delays from patients and insurance services.

Incomplete or incorrect information in the customer card causes a problem and increases the employee’s workload. The doctor may confuse the patient cards; hence one patient will have inaccurate information in the profile, while the other will lack it. For example, incorrect information can be the date of birth, gender, diagnosis, and treatment dates. Billing staff does not have to go through each case in particular; their job is to enter data provided by the doctor. It is better to check the correctness of filling out the patient cards immediately before transferring to other departments.

NPI is a ten-digit code that a medical worker must issue after graduating from a college or institute. The number is assigned to Medicare and Medicaid Services providers for convenience. The coding rule was developed together with HIPAA in 1996 but began to be released only in 2006. Before its appearance, there was constant confusion because it was impossible to identify a health care provider. The number is public and available on the base if necessary. It is required to identify the person performing direct medical activities; people who issue invoices are not required to have this option. The NPI code is registered once and remains the same when changing jobs and locations. The pharmacy staff uses it to identify the person who wrote the prescription. Likewise, insurance companies can identify the claims provider and contact them in case of questions.


Demaerschalk, B. M., Berg, J., Chong, B. W., Gross, H., Nystrom, K., Adeoye, O., Schwamm, L., Wechsler, L., & Whitchurch, S. (2017). American telemedicine association: Telestroke guidelines. Telemedicine and E-Health, 23(5), 376–389. Web.

Grant-Kels, J. M., Kim, A., & Graff, J. (2016). Billing and up coding: What’s a doctor-patient to do? International Journal of Women’s Dermatology, 2(4), 149–150. Web.

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