time to get serious about coding and documentation

Get real about coding & documentation


Challenges to your coding will not be coding away anytime soon. There continues to be a belief among payers and employers that there are millions of dollars in recoverable medical expenses in challenging of electronic health record documentation. while the unfortunate reality is that far too many physicians coding patterns remain unchanged and documentation is lax, making them easy targets for scrutiny.

At risk is more than money, as Coding & Documentation is no longer just about recovering dollars from physicians for poor documentation practices, it may also be a reportable event to the regulators. The Centers for Medicare and Medicaid Services (CMS) and most states have requirements that obligate health plans and insurance carriers to report suspicion of fraud. Suspicion is not a determination, and if reporting is to meet the requirements, it cannot be considered defamation.

Fraud is committed when any person knowingly and with the intent to defraud presents, or causes to be presented, any information as part of a claim for payment which is known to

(1) contain materially false information concerning any material fact, or

(2) conceal for the purpose of misleading, information concerning any fact material thereto.

However, Billing mistakes/errors occurring during the conscientious effort to perform correctly are understood to be “innocent mistakes” and not fraud. However, physicians have been prosecuted for fraudulent billing under the concept of “reckless disregard”. When it can be shown that they did not pay attention to the billing requirements, did not review the billing requirements and changes to the requirements, did not take necessary action to assure that billing staff were properly trained and did not take any action to review claims for accuracy and appropriateness. Lack of knowledge of inappropriate and incorrect billing practice is reckless disregard and not an innocent mistake if the provider willfully refused to learn what is required.

The CPT code billed is a representation by the physician that the services provided are fully those described by the CPT as detailed in the CPT Manual. The CPT coding system was developed by and is owned by the American Medical Association, (AMA). It is the accepted coding system. CPT codes are a language, and the definition of that language is the explanation of the services, the range, and depth of those services, as described in the CPT manual. A liability is created when the medical record description of the services provided does not reasonably match or is inconsistent with the description of the CPT code.

The level of services provided must also be commensurate with the diagnosis under treatment. While all the requirements of a level of care may be fully and completely documented, does the diagnosis under treatment warrant that level of service? Increasingly payers are using computerized models to compare CPT codes with the diagnosis codes and identifies patterns of what they allege to be excessive services for the diagnosis listed. For example, an ear infection in an otherwise healthy patient would be difficult to justify a level 5 E&M, even if the level 5 were fully documented according to the documentation standards.

Payers analyze submitted bills comparing them with other physicians of the same specialty, and with coding patterns submitted to Medicare and to commercial carriers. Patterns that deviate from the norms become targets for audits.

Billing everything at level 4 or 5 of E&M codes is a red flag. So is billing everything a level 3. It may be that, in the past, plans gave physicians coding an “average” of a level 3 a pass, but not anymore. They are just as likely to challenge all level 3’s, as they are any other abnormal pattern.

Submitting a bill coded for services not adequately documented can result in an escalating series of consequences. Not documented is not provided. And your documentation is your medical record.

At a minimum, the payer would want to recover the difference between what was billed and what the medical record supports as a “more proper” code.

And there is the serious potential of extrapolation of the results. Extrapolation is applying the findings of a sample to the whole. If 10% of the billings are not supported, then 10% of the past year’s claims must not be supportable either. These findings are extrapolated and restitution is sought for several years of past billings. And extrapolation can reach back up to 7 years. Generally, commercial plans do not go back more than 3, Medicare often goes back the full 7 years.

Any financial hit is in addition to the potential of a report for suspected fraud to Medicare and State regulators, who could decide to take action on their own. A finding from a governmental audit will often trigger commercial plans to seek their own reviews and restitution.

Perfection in documentation is not expected and is not realistic. The equation often used determine the innocent mistakes vs suspicion of fraud is that a chart audit is expected to find documentation supporting billings in 80% of the charts reviewed. If more than 20% of the charts do not support the codes billed, suspicion of fraudulent claims is often reported. This equation is not in the regulations, and each plan can define when they are obligated to report suspicion of fraud.

Once there is a request for medical records it is too late to discover the rules of coding and documentation.

Deal with the reality, not what you would like to believe. Learn what needs to be included in your documentation to support your coding. Read the CPT book for the codes you frequently bill. The documentation requirements are detailed for each CPT.

Look to your specialty societies for assistance for the uniqueness of your practice and take advantage of coding and documentation seminars available.

A review by an independent expert (under the auspices of your legal counsel) may be a solid investment. The right expert can show you how to simplify your documentation requirements and meet the regulations. Templates, customized for your specialty, are often created and used.

Codes should only be selected by the physician, however, the more the physician’s staff knows; the more they can assist in, complete supporting documentation and correct coding. The final responsibility remains the physician’s – their name is on the bill.

No, you can’t hold medical information hostage for payment


 

Medical Record

Yes, lawyers can hold a client’s files until their bill is paid, such as the power of the attorney’s lobby, but refusing to provide medical records on behalf of a patient that owes you money is not a proper collection tactic.

From the standpoint of public policy, the belief is that medical care, and the information that is needed to provide that care trumps getting your outstanding bill paid.  Simple as that.

 

In fact, Federal regulations 45 CFR 164.524(c)(4) is very specific as to your right to charge an individual for a copay of their electronic health records, however, you cannot withhold or deny a patient a copy of access to that record on the grounds that they owe you money.  And in NY physicians are limited to a per page charge of $0.75 to make copies of that record.

Now the regulations that set the per-page price do not contemplate passing on the medical record in an electronic manner so the guidance would be to charge the cost of the media material and a nominal fee.  However, the regulations speak to providing the patient with a copay of the records, there is no provision that mandates that you pay for the cost of mailing or otherwise sending the records. 

 

Therefore, you may want to set up a policy that you will provide the records, but that they must be picked up by the patient or an authorized representative at your office, or that the patient provides you with a paid Federal Express or another secure delivery service.  You can invite the patient to either pick up the records, send the pre-paid delivery envelope, or pay the cost of such.  All should be received by your office prior providing.  Collecting the records by billing is unlikely.

 

6 SIMPLE WAYS TO REDUCE THE ADMINISTRATIVE BURDEN IN A PRACTICE

Now if the patient says they cannot afford to pay for the records, you are entitled to ask for documentation of their financial hardship to then waive the cost.  In such incidences, keep your cost exposure to paper copies, no mailing, require to pick up.

 

Similarly, physicians have crossed a red line when they have not reported medical testing results to patients with outstanding balances.  There is an obligation of the physician, often delegated to staff to report test results.  Not only can test results not be held up due to outstanding balances, it is the practices obligation to contact the patient with the results, it cannot and should not pass that responsibility to the patient.  Yes, you can tell them when the results are in if they choose to call, but you have to reach out and present the results if they don’t.  And do so reasonably soon after receiving the results.  This is not only good for patient satisfaction but also good for patient care, especially if those results result in the recommendation for further care or testing.

 

Read More About: CureMD recognized one of most promising healthcare solution provider

CureMD Most Promising Healthcare Solution Provider

The unfortunate reality is that once medical services are provided there may be reduced interest by the patient in paying for them.  You are most at risk for non-payment on your commercial patients, where coverage and auditions, as well as nuances of approval and networks, is often confused.  Here you might want to consider contingent credit card authorizations to give you some cushion if the information you rely on from the payer as to coverage, deductible levels, and copays is less then accurate.

Former CIA Officer REVEALS: A confidential trade secret of the U.S. intelligence community

Telemedicine

Telemedicine – Adding a service and revenue to your practice


Physicians have long misunderstood the cost of an office visit.  Copays, generally not more than $20 seem like a limited disincentive to an office visit.  But the cost of an office visit was never just the copay, it includes the cost of the patient’s time, and hassle to schedule, the interruption their day, travel to and from an office visit of say 20 minutes.  To the patient, what are nearly 3 hours of their time worth? A complete morning or afternoon lost to a physician office visit.  And now add to that deductible, large deductibles.  All motivating patients to find a way to access care for less.

And patients are, the use and acceptance of urgent care centers continue to grow.  While studies show that most patient understands that the use of an urgent care center is episodic and that some even say they go because they don’t want to bother the physician when they are not really that sick, convenience is the greatest draw of the centers to patients. And now with most health plans providing coverage, convenience trumps continuity of care. Continue Reading

Tips to Plan Holiday Schedule and Reduce Stress


Imagine having a follow-up appointment you scheduled for your Grandma being postponed, even though it was booked 2 months prior. This inconveniences the patient and frustrates the physician for having not met expectations.

This is a common occurrence among physicians worldwide, unavoidable at times due to emergencies or family commitments, but usually due to a lack of planning for the holidays. Unstructured scheduling of staff leads to misunderstandings amongst them and ends up adversely affecting the patients.  Focusing on the following can help:

  • Holiday Closure Policy:

This policy must list the days that some or all of the staff has off, especially non-standard days when the office could stay open. Releasing this policy early in the year can help prevent frustration for patients and staff. It will also be beneficial in planning for the holidays. Continue Reading

6 Simple Ways to Reduce the Administrative Burden in a Practice


When a small practice attempts to do everything themselves, problems will almost certainly arise. Between managing operations, scheduling, billing, account management, customer service, and providing medical attention, administrative duties can become too demanding and downright burdensome for a small staff. In fact, it may often divert attention from the core focus of providing care.

How can this be avoided? A recent discussion between MGMA Members Community provided overburdened practitioners with valuable feedback. Some were of the view that practices should outsource their administrative duties while others provided tips on how to streamline operations to reduce the burden.

Here is what they recommended:

All About MIPS: How to Prepare for this Reporting Period


Are you prepared for MIPS? As the deadline to collect data is approaching, it is time for providers to get serious about documentation to avoid penalties. MIPS reporting can be stressful, confusing, and haphazard if you are not prepared. However, in order to avoid penalties and maximize incentives, it is important to assess how you have fared. While you may require special assistance in the form of CureMD’s MIPS consultancy services to properly equip you with a penalty protection plan and help you understand how to maximize your returns, CureMD can simplify the technicalities for you. Enhance your understanding of eligibility, scoring, performance thresholds, and alternative payment models here. Get More Information on MIPS Reporting 2017

 

MIPS-Penalties-Protection-Plan

11 Fundamental Changes in the EMR Market


11 Fundamental Changes in the EMR Market.

For nearly a decade, the $28 billion Electronic Medical Record (EMR) market was on a foreseeable path with roughly 20 similarly-sized competitors and many smaller participants offering software systems and support services. A new report from Kalorama Information says the EMR market is confronting changes that will determine how healthcare providers operate moving forward. Per the report, the market is consolidating, leading to a decrease in EMR support services and creating issues for providers. To illustrate, here are 11 ways the EMR market is changing:

  1. The EMR systems market has been consolidating for years. While there are hundreds of EMR vendors today, consolidation in the industry has accelerated in recent years. In a meaningful use (MU) attestation in 2012, the top 15 EMR vendors of 336 hospitals surveyed represented 75 percent of all providers attesting. On the inpatient side, this concentration was even more pronounced with the top six representing 75 percent of total hospital attestations. Read More