Remorse Code: Mistakes that Prompt an Audit

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 - Gavel

Under the False Claims Act, it is illegal to submit a false or fraudulent claim to Medicare or Medicaid, intentionally or not. It is the physician who bears responsibility for the accuracy of claims submitted if billings raise questions. Good practices may help avoid the heartache and cost of delayed reimbursement or audits.

Big brother & you

In an analysis of coding trends and physician billing patterns, the Office of the Inspector General placed cardiology sixth on its list of specialties for high billers to Medicare in 2010. Overall, the number of these outliers was small—a mere 1,669 physicians across all specialties, or less than 1 percent—but this sliver selected the two highest codes for evaluation and management (E &M) services 98 percent of the time, for a cost of $108 million.

That’s the kind of aberration that raises red flags for payers. The 2012 Coding Trends of Medical Evaluation and Management Services report did not attempt to determine if the billing practices constituted fraud. But it identified the physicians and recommended that the Centers for Medicare & Medicaid Services (CMS) keep tabs on them. In response, CMS said it planned to ask its Medicare contractors to produce billing reports that compare a physician’s coding and billing patterns against his or her peers to spot high billers and potential overpayments. It also said it would scrutinize not just the 1,669 physicians but expand its scope to 5,000.

 - RAC Denials Reversed, Q3 2013

“The government has the full deck of cards. They have all the claims data,” says Betsy A. Nicoletti, MS, a Springfield, Vt.-based certified professional coder, consultant and author of several books and a website on medical coding. “They know if you are an outlier or not. All we have is the ace of spades and the two of hearts and it leaves us at a disadvantage.”

Some fundamental practices may help physicians and their institutions reduce that handicap. Given that a physician holds responsibility for coding claims—and faces the hassle of challenging denials, or worse yet, penalties if found guilty of false or fraudulent claims—he or she   should know how to code what he or she practices, Nicoletti and other coding experts say.

Eric L. Altschuler, MD, PhD, goes one step further. He proposes that coding and billing basics be part of medical school training, a concept that he and colleagues are pilot testing at Rutgers New Jersey Medical School in Newark, where he teaches in the physical medicine and rehabilitation department. To date, they've developed four one-hour lectures, which are generally well accepted by second-year medical students (Med Educ Online Aug. 12, 2013).

Rather than see coding as a burden, physicians should recognize it reinforces good patient care, Altschuler says. “It is a powerful tool,” he says. “It helps the doctor write better notes and that leads to better medicine.” Correctly coding and billing also facilitates timely reimbursement and avoids the cost and angst of an audit.

Nicoletti agrees that a physician should learn the rules of coding and do the bulk of coding but draws the line at tasks that take time away from patient care. “If there is something unusual or they can’t find a diagnosis code then I don’t want physicians spending 5, 10, 15 minutes looking that up; put that to a coder,” she says. Coders also might apply modifiers and check for bundling, she adds.

Document everything

Debra Mariani, a certified professional coder and a senior specialist who works on coding issues at the American College of Cardiology, observes that a common mistake cardiovascular physicians and practices make is insufficient documentation. “No one wants to take the time to do it properly because they are busy and they want to take care of their patients,” she says. “But the only way to protect yourself is to write down exactly what you have done. That will be more evident in the days of ICD-10.”

Staying on the right side of the law

As part of an education initiative, the Office of the Attorney General published a roadmap for physicians to help them stay compliant with the False Claims Act and other healthcare laws. It emphasized the importance of not upcoding services and offered these tips.

Don’t bill for services that:

  • Were not performed;
  • Were not medically necessary;
  • Were performed by an improperly supervised or unqualified employee;
  • Were performed by an employee who had been excluded from participation in federal healthcare programs;
  • Were of such low quality that they were virtually