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.