America's Billing Specialists

America's Billing Specialists Providing Medical Billing services to healthcare professionals Providing Medical Billing Services, so you can focus on caring for your patients


Let's talk about another problem in Medical coding.
2) Poor documentation.

In essence, poor documentation is anything that inhibits a clear presentation of a patient's story. For instance, if a provider is documenting congestive heart failure, he or she will need to include the acuity and type of congestive heart failure to ensure the highest level of specificity, Instead of just documenting congestive heart failure, which is unspecified, he or she could document acute on chronic systolic congestive heart failure, which would take the diagnosis to the highest level of specificity. All other notes should reflect care and treatment to support the acute on chronic systolic congestive heart failure.

While that may seem like a minor issue of semantics to those outside—and even some inside—the health care system, its potential ramifications are real and significant. The ramifications of poor documentation are endless, They start at the front line and, most importantly, with patient safety issues. From there, the opportunities flow into financial repercussions for the facility. The consequences of poor documentation all come full circle.


Lets look at our first common problem in Medical Coding.

1) Not coding to the highest level--
Insurance carriers often deny claims for not being coded to the highest level of specificity or they may consider the diagnosis truncated. As many billers are not coders, they often don’t understand what has gone wrong or how to fix it.

What is the highest level of specificity?
If a service line is denied for this reason, the payer is saying that the diagnosis code needs to be more specific. Some diagnosis codes are only three or four digits, but many are five.
The diagnosis must be coded to the absolute highest level for that code, meaning the maximum number of digits for the code being used. You may have a four-digit diagnosis code that needs to be five digits to be accepted.

Some practice management systems have scrubbers that will catch under-coded diagnoses and give you a warning. Sometimes, the biller may recognize a truncated diagnosis (or a diagnosis requiring an additional digit).

In either case, the biler should go back to the coder or provider and ask them to be more specific with the diagnosis code, so the claim can be resubmitted.


Common problems in Medical coding.

1) Not coding to the highest level.
2) Bad or Missing Documentation.
3) Not having access to the provider.
4) Failing to use current code sets.
5) Over or under coding.
6) unbundling codes.

Some of these issues can lead to audits and investigations.. We will go into more detail soon


To help establish medical necessity for each procedure the care plan should outline specific and measurable goals for each service. For example:

98940: Show favorable changes to PART exam, such as reduced pain and increased ROM by a certain amount by a certain date.

97140: Reduce quantity/frequency/locations/severity of trigger points by a certain amount by a certain date.

97112: Improve muscle strength from 3/5 to 4/5 by a certain date. Or restore gait to normal by a certain date.

These goals are clearly separate and distinct. And they are very specific and measurable. Functional progress should then be demonstrated at each re-exam by achieving the goals, or remarking about lack of progress if applicable. Also, remember that 97140 and 97112 are timed-based codes and this encounter would need to document a minimum of 23 minutes for each service for them to be billed together on the same visit

If these steps are followed, reviewers should have a hard time denying a case like this.


America’s Billing Specialists May be Your Solution

More money, fewer headaches; more strategy, less administration results in more billable clinical time. You get to do what you are best at and use our critical insights to take greater control of your business.

Interested in learning more about how America’s Billing Specialists can help your practice be more successful? Please contact us for more information.


Why let us take care of your billing?
Our team only has one purpose, to increase the profitability of your practice. We review and post all payments ensuring that the carriers are paying the correct amount and preventing incorrect adjustments. Every outstanding claim is tracked until it is processed and paid to its fullest. This is not a separate team. We are integrated with your existing staff and have the same goals in mind. If the practice does not make money, We do not make money. We work closely with office staff to ensure an efficient overall workflow and provide training when needed. The practice also gains access to a large combined knowledge base of billing experts to aid in navigating the ever increasing industry changes.


We understand that your job is to focus on your patient's safety and health. Our support team can focus on your billing needs and help you be more effective with collections.


206 Timber Creek Ln SW
Marietta, GA


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