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Common Missteps in ABA Therapy Coding and Billing


Medical billing and coding can be a very complex process. Adding to this complexity in the ABA world is the fact that CPT codes are still Category III (temporary) and are thus not nationally recognized. When coupled together, even the most attentive billing team can experience the occasional misstep.

One of the best methods to avoid making common billing and coding mistakes, is knowing what they are. Amvik Solutions knows that a lot of your time and effort is placed into the billing process, and that the last thing you need is a denial. Here are a few tips to avoid those common mistakes that can lead to a claims denial.

Consider the following errors that are frequently made in the billing and coding processes:

  1. Incorrect patient identifier information. A minor mistake like a misspelled name can easily lead to a denial. Your billing team should be detail oriented and ensure the patient’s name is spelled correctly, date of birth and gender are correct, policy number is valid, their relationship to the insured is accurate, and diagnosis codes match the procedure performed. Primary insurance should also be noted, as well as any group numbers, if necessary.
  1. Failing to verify patient’s insurance coverage. ABA therapy coverage varies by insurer so it is vital that your billing specialist(s) verify if services are covered or if coverage is terminated. It’s also important to make sure that maximum benefit (cap) has not been met. Health insurance can change at any time, therefore it is essential to constantly confirm coverage—a proactive approach can save your billing department from headaches later on.
  1. Duplicate billing. This mistake is often the result of human error; whether re-submitting a claim without effectively following up with the insurer or cancelling a session or test without removing it from a patient’s account. Your claims billing team should have a system set in place, which should include proper coding of services and applicable modifiers, to evaluate potential duplicates. Suspicious entries will contain duplicate information such as:
  • HIC number
  • Provider number
  • From and through date of service
  • Type of service
  • Procedure code (and modifier)
  • Place of service
  • Amount billed

 

  1. Not meeting deadline. Even if your claim is properly documented and completed, but you fail to submit it within the deadline window, it’ll likely be denied. The clock usually starts on the date the service was provided to the patient or the “From” date on the claims form. Deadlines vary by payer, with Medicaid allowing a full year to submit from day of service, to commercial insurers like UnitedHealthcare only allowing 90 days. It’s a best practice to have this information handy so you don’t run the risk of missing a due date and it’s also vital to understand what supporting documentation is needed to receive reimbursement in case you need to appeal in a timely manner. 
  1. Failure to obtain referral or prior authorization. As coverage varies by insurer, some payers will require that you obtain a referral or prior authorization before providing services or performing a procedure. Usually, it is the primary care physician who issues the referral and the payer who provides the prior authorization. Remember, this still does not guarantee payment. Services and submitted claims must be: supported by  medical necessity, filed within the proper timeline, and submitted by the provider noted in the referral or authorization.
  1. Illegible documentation. Billing and coding errors can occur from something as simple as sloppy handwriting and documentation. If your billing team is unable to properly read documentation, they may inadvertently assign the wrong CPT code, undercode a patient’s bill, or perform some other mistake. Ask your therapists and other healthcare providers to write neatly and correctly.  
  1. Coding issues. As previously mentioned, the current CPT system can be a bit complicated for inexperienced and experienced billing specialists alike. Outdated codebooks, inputting the wrong CPT codes, point of service codes, coding mismatched treatment and diagnostic codes, or failing to input codes for all services performed by an ABA therapist, can all lead to your claim being denied. Coding issues can be directly tied to documentation; billing and coding must align with the services documented. Insufficient documentation, or none thereof, of any services cannot be billed.
  1. Upcoding, undercoding, and unbundling. Upcoding is the entering of a higher-paying code on a claim for services not rendered. Upcoding increases the total amount a patient owes for receiving care and is illegal. Undercoding occurs when codes are left out of a bill. Providers might undercode to avoid audits or minimize a patient’s cost, which is also illegal and can lead to legal issues. Unbundling is when test and procedures are billed separately per component, which can increase the totals in comparison to their special reimbursement rates. These three practices are not legal nor ethically acceptable and should thus be avoided.

To Avoid These Errors

There are a number of steps that can be taken to help prevent these basic, but costly errors, including:

  • Support staff should verify patient and insurance information during the patient intake process. Insurance companies should be called before treatment to validate policy number and coverage.
  • Coordinate with providers and the billing team to ensure that information is being handled adequately and being passed along appropriately. Determine who will compile the information, what personnel will be responsible for billing, and when that should be completed.
  • Invest in training your staff or billing specialist on the latest codes and billing trends. Billing codes change over time because of healthcare regulations and other reasons. By keeping up with new codes and billing procedures, your team can be ahead of the curve.
  • Stay vigilant and always make sure to double check all information. Thoroughly review all patient’s bills and documentation to ensure there is no vital data mission. Make sure to consult with therapists, physicians, and other medical professionals involved whenever you have a question about what should or shouldn’t be billed.
  • Follow up on claims to help you avoid errors and create duplicate billing. Representatives working on the claims might be able to provide you with specifics to resubmit a claim before it gets denied.

Let Amvik Solutions deal with the stress of billing.