It actually happened too.
Consider a CCSD code for a follow up consultation = 20310. Now consider the CCSD code for an ECG = 20110.
A consultant surgeon couldn’t understand why he was not getting paid the right values for his follow up consultations i.e. £150. Instead, he was getting either £72 from one insurance company, £96 from a second or zero a third. The reason was clear when MHM investigated.
It was because some of the invoices for his follow-ups consultations had been coded as 20110 [ECG reporting] and not 20310 [follow up consultation]
Insurance companies were seeing 20110; some were querying the code when the patient hadn’t had an ECG but others were happily paying the fee for the 20110. The third insurance company did not cover 20110 ECG as part of their patient offering and thus declined to pay anything.
When numbers were audited the average discrepancy was £65. When all numbers were in, the number of errors equaled 11. And thus the client was out of pocket by approximately £725.
The consultant concerned was not happy, especially when his work did not require an ECG anyway. Thus one day’s analysis and the consultant now receives the right fee – because the right code and fee are being used.