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.

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Obamacare to be repealed? Republicans push on


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For anyone who’s lost out on fulfilling a dream because they depleted their savings on medical expenses, those who avoid going to the doctor for fear of a huge medical bill, and those that have lost loved ones to cancer, Obamacare was a tremendous blessing. Highly popular amongst Americans initially, President Obama’s signature health care law has provided health coverage to approximately 20 million Americans who were unable to afford health insurance previously. This accounts for approximately 15% of the American population who currently has access to healthcare. Possibly inspired by Britain’s NHS system, the Affordable Care Act’s main objective is affordable healthcare for all, eventually leading to a healthier and happier America. However, Britain’s NHS is considered a huge burden on taxpayers and is facing allegations of inefficiency, and Obamacare seems to be equally in trouble as Republicans are working to replace the law with a new version called the Better Care Reconciliation Act of 2017. Continue Reading

5 Ways Affordable Care Act Affects Reimbursement


The Affordable Care Act (ACA) enters the mature phase of its implementation, which is going to impact physician revenue in different ways – some favorable, others not much. Therefore, it is time for physicians to prepare for challenges ahead.  Here are 5 ways that the ACA will impact your income in the years to come.

Extra services covered in insurance

According to the ACA, more services will be covered by insurances that were not covered previously. This step has gained immense support because “patients who have insurance and access to primary care have better health outcomes,” said Jeffrey Cain, MD, President of the American Academy of Family Physicians (AAFP).

Now patients won’t have to pay from their pockets for medical services like blood pressure checkup, mammography, childhood and autism screenings, and contraception.

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Increase in patient volume

More and more Americans will be insured in the years ahead and looking for primary and eventually specialty care. This means primary care practitioners can now enroll new patients bringing more money. However, most of these patients will come from low-income families, who will be insured on subsidized rates and pay out of pocket.

Increase in out-of-pocket payment patients

Practitioners will be forced to rethink their patient payment policies because of changes in the ACA that will increase the trend of out-of-pocket charges. Kaiser Family Foundation found out in a survey that 72% of employees had a deductible for single coverage, which was 20% more from 2006. It further reported that annual deductible for 72% of employees was $1,097 in 2012, which was 88% higher since 2006.

Rise in penalties will impact reimbursements

CMS incentive programs, Meaningful Use and Physician Quality Reporting System (PQRS), will reduce or stop payments from 2015. Meanwhile, physicians who haven’t complied with the programs will bear financial penalties.

From fee-for-service to pay-for-performance model

Accountable Care Organizations (ACOs) are a breath of fresh air for the physicians trying to decrease cost without compromising quality. This new payment model, pay-for-performance, was introduced to maximize the benefits for patients to improve quality of care while reducing costs. However, as the Model matures, physicians will be required to report their performance to CMS in order to participate in the shared savings.