Data Entry

Each time information changes hands or is acted upon outside an automated system the risk of error increases.

Source documents completed during the office visit are usually given to a designated person within the physician’s office. This person ensures that source documents for each patient seen that day are collected. They may, or may not, review them for completeness. They may add, delete or modify the entries. For example, when a physician performs a procedure not listed on their preprinted source document, they note the service provided in space often provided for this purpose. Someone else may add the procedure code, diagnosis code and fee to the source document. 

Completed source documents can be entered into the physician’s own billing system and forwarded directly to Medicare. They may be entered into the physician’s system and subsequently sent to a clearinghouse which, in turn, submits the claims to Medicare. Finally, source documents may be sent to an outside billing agency that will enter the data and submit it to Medicare either directly or through a clearinghouse. 

The person who actually enters the data (whether an employee of the physician or an outside agency employee) uses the source document as a guide to identify patient, provider, diagnosis, procedure coding and other information needed for claim coding. They may also resolve any missing, incomplete or erroneous information detected either by computer software or document review. 

Employees of the physician, or an outside billing agency, may misinterpret source document information, mis-key information into the system or add, delete or modify information on source documents. For example, the physician notes “I & D,” [incision and drainage] on the source document. Another person (within or outside the physician’s office) will decide which one of the 10 incision and drainage codes will be billed. The wrong choice may effect coverage and payment. Additions to, deletion of and modifications of source document information by data entry persons and other reviewers may not be supported in the patient’s medical chart. Decisions made during the data entry process may reduce a physician’s Medicare payment or create an overpayment. 

MEDICAL BILLING SOFTWARE  

Basic Software

Billing software that requires users to input extensive information increases the risk of claim error.

Basic medical billing software is widely distributed by Medicare fiscal agents and the private sector. Our review of Internet literature on medical billing software indicates that this type of software is inexpensive and in widespread use. Users of non interactive software key most, if not all, claims information onto a claim facsimile. The software manipulates these entries to produce an electronic claim. Typical errors involve entry errors, incorrect or missing patient or provider information, incorrect or incomplete diagnosis codes or invalid Current Procedural Terminology (CPT) codes. 

More sophisticated basic software may recall patient and provider billing information when a patient’s last name, Social Security number (SSN), medical record number or other identifier is entered. The user then enters line-by-line information about the medical services provided onto the partially completed claim. 

Software feedback to the user, if any, is limited to program checks such as validity tests, completeness tests, logic tests and other conditions established by the software developer. Theses program checks may identify missing data required for processing. They may check to ensure that the SSN contains nine digits or that the procedure codes used to describe services are the correct length. If data entry errors exist, the software alerts the user. The user must determine how to resolve the problem(s) and re-enter the correct data. 

A vulnerability exists because each person handling source documents is in a position to misinterpret, mis-key or deliberately alter the original information recorded by the physician. Information needed to prepare a claim that must be manually researched increases the chance of billing error. The number of procedure codes, diagnosis codes and other information needed to produce a claim increases the likelihood that a billing error will occur.