Coding and billing errors

A coding or billing error is a mistake in the paperwork that turns into a denial or a bill. The plan reads the codes on the claim, not your records. If the codes do not match what happened, the plan may deny, pay less, or ask for more. This is often fixed by the provider’s billing office, not by an appeal.

What this means

A claim carries a diagnosis code (what condition) and a treatment code (what was done), plus the provider, date and place. Typical errors include:

• a code that does not match the service you had;
• a service billed twice (a duplicate claim);
• two services billed separately that the plan says belong together (a bundled service);
• a routine preventive visit coded as a diagnostic one, which can change what you owe;
• a missing detail, such as a referral number or the date of onset;
• the wrong plan or member number.

A claim returned for missing information is often a rejection, not a denial: it was never fully processed. The provider can correct and resend it. A real denial is a decision not to pay and carries appeal rights.

Who acts first. In most cases the provider’s billing office. You can ask it to correct and resubmit, but you are the one who sees the explanation of benefits and can push. Both of you keep the deadline in mind.

What you can ask for.

• The codes. A non-grandfathered plan or insurer must provide the diagnosis code, the treatment code and their meanings as soon as practicable on request. A denial notice must say that they are available on request. Asking for them cannot be treated as filing an appeal or a request for external review.
• The reason. A denial notice must give the specific reason and the plan provisions relied on, and for non-grandfathered plans a denial code and its meaning.
• Records. Under the federal health privacy law you have the right to your provider’s billing records and your health plan’s claims records. The plan or provider must act on your request within 30 days, with one extension of up to 30 more days if it explains the delay in writing. Only a reasonable, cost-based copying fee is allowed.
• An itemized bill. We found no general federal law requiring an itemized bill for insured patients, so use the records right above, or ask the provider directly. Some states have their own rules.

Preventive care. A non-grandfathered plan must cover preventive services rated A or B by the United States Preventive Services Task Force, recommended immunizations, and specified preventive care for children and women, without cost sharing. If you were billed for a visit that was preventive, ask the billing office whether the codes reflect that.

What to do

1. Read the explanation of benefits and the bill side by side. Look for the service, date and provider. If the plan says a code does not fit, note which one. (You.)
2. Ask the plan for the codes it used. The request letter for the denial in writing helps if you do not have a notice. (You.)
3. Ask the provider’s billing office for the itemized bill and the codes it sent. Ask what it will do if they are wrong and how long it will take. Use the note to the doctor’s office. (You.)
4. Ask the billing office to correct and resubmit. Ask for the date it resubmitted and for proof. (The billing office.)
5. Ask the plan to reprocess. Once the claim is corrected, call and use the script for asking for reprocessing. Write down the name and reference number. (You.)
6. Appeal if the plan will not change the decision. Use the coding error appeal letter and attach the corrected claim and your records. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial. Do not let the deadline pass while the billing office works. Check the date on your notice, which controls. (You.)
7. Ask the provider to hold the bill. See the guide on the bill while you appeal. (You.)

What the plan may say, and what to say back

“The procedure code does not match the diagnosis.” Ask the plan for the codes and their meanings. Ask your doctor’s office whether the codes it sent describe what you had.

“This is a duplicate claim.” Check the explanation of benefits for two lines with the same date. Ask the billing office whether it sent one claim or two.

“This service is bundled into another.” Ask the plan to state the rule it used. Ask the billing office whether a modifier or separate record is needed.

The rule

A non-grandfathered plan must provide the diagnosis and treatment codes and their meanings as soon as practicable on request, and asking cannot be treated as an appeal. 29 Code of Federal Regulations (CFR) 2590.715-2719

Watch for

• External review. A pure coding error is usually not a medical-judgment question, so the federal external review process may not apply. If the plan’s denial depends on medical judgment, it can.
• Timely filing. If the corrected claim goes in late, you may face a new denial. See the timely filing guide.
• Bills arriving before the fix. A provider may send you a bill while the correction is pending. Ask for a hold in writing.

What next

• Fix a denial without an appeal: how to get a paperwork denial corrected.
• Itemized bill: how to ask for one and read it.
• Timely filing, coordination of benefits and eligibility denials: when the problem is dates or another insurer.
• Billing and paperwork topic page: all related guides and letters.