How to Avoid Therapy Billing and Coding Errors

By: Cheryl “Chae” Dimapasoc Canon, PT, DPT;  OptimisPT Director of Implementation and Compliance

Medical coding 

 “Do not code it or bill for it if it’s not documented in the medical record” 

When was the last time you completed a sanity check on your therapy coding and billing within your practice?  Did you know that under the “False Claims Act”, you can be guilty of fraud if you (accidentally) overbill Medicare?  A reimbursement request based upon a billing or coding error is considered a “false” claim under the FCA. As such, it violates the statute and it is considered a form of fraud against the government. Minimally, this triggers the potential for civil liability since the FCA’s civil enforcement provisions do not require bad intent in order to establish culpability.

Here are some key questions, compiled by billing experts, to help you perform a sanity check and prevent accidental billing and coding errors.

  1. Who is auditing your documentation vs what is being billed?
  2. Do you have a process where all chart requests from your payers are being reviewed by the signing therapist before the records are sent?
  3. Who in your company is receiving the requests?  Is there a workflow that the appropriate team is aware of the requests and reviewing before answering?
  4. Are you learning from any take-back requests from your insurance company?
  5. Is your Billing Department current with coding training and or payer updates?
  6. Does your billing department attend free webinars provided by payers?

In addition to ensuring you have a workflow to address those question above, here are some of the top billing and coding errors you’ll want to avoid:

  1. Missing or incorrect patient information


  • Name is spelled correctly
  • DOB and gender are accurate
  • Correct insurance
  • Valid policy number
  • If group # is required, it is entered
  • Relationship to insured is accurate
  • Diagnosis code matches procedure performed
  1. Coding issues
    • Upcoding: submitting a code for an item or service that is reimbursable at a higher rate than the item or service that was actually rendered.
    • Coding is not specific enough (frequently using unspecified codes can lead to a yellow flag)
    • Using outdated codes
  2. Unbundling – charging procedures separately so that the provider receives a greater payout.
  3. Billing for services deemed “not medically necessary” – Even if you believe that the services you rendered were medically necessary, if CMS does not, then the services are not eligible for federal program reimbursement.
  4. Physician Certification Fraud – For services requiring a physician certification, billing for these services in the absence of a valid physician certification is yet another form of prosecutable healthcare fraud.
  5. Missing Authorization or Referral – Payers are expanding the number of visit types and procedures that require prior authorization—leading to an increase in denials for some practices. It is estimated that 80% of denied claims have to do with no authorization being obtained, or authorizations being requested improperly.
  6. Poor or missing documentation – Documentation needs to, not only be present, but must  support medical necessity.  In the absence of specific supportive documentation (i.e. name of exercise and parameters and progression over time, manual treatment performed, etc), your claim could be denied.

Preventing claim denials can save you a lot of time, energy and money. Developing specific and efficient workflows that involve your entire team will help prevent many of these errors.