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.

MIPS Delay on the Cards


MIPS Delay on the Cards

MIPS (Merit-Based Incentive Payment System) delay & shorter reporting periods are the options CMS is willing to explore.

  • On July 13, at the congressional hearing on the Medicare Access and Chip authorization act, CMS Acting Administrator Andy Slavitt did not rule out the possibility of a MIPS delay.
  • Originally, MIPS is scheduled to start from January 2017 with payment adjustments beginning in 2019.
  • Since the release of the proposed rule, various physician groups have called for greater flexibilities, many of Which center around pushing the start date forward by at least six months.
  • With the final rule scheduled to release on November 1, leaving physicians with only two months to prepare CMS is Open to give physicians more time, said Slavitt. Read more

5 EHR Infographics that every provider must read


EHRs are an important element of the healthcare market. It is vital to realize the importance of EHRs and the direction the entire industry is headed in. With the help of info-graphics it is easier to show marketing trends, the following article will show you some of the best info-graphics relating to healthcare, ranging from subjects like; when to get a new EHR? What share do different vendors in the market hold? Does technology really improve the way a practice is run? Find out with below amongst many other important subjects.

1) Electronic Health Records Infographic

How do electronic health records (EHRs) connect you and your doctor? In the past, medical data was only stored on paper, making it difficult for your health care providers to share your information. Read more

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2) The 20 Most Popular EHR Software Solutions

As the deadline for implementation in the U.S. draws near, talk of electronic medical records (EMR) and electronic health records (EHR) software is a hot topic at the doctor’s office lately. These systems assist medical practitioners in the creation, storage, and organization of electronic medical records, including patient charts, electronic prescriptions, lab orders, and evaluations (just to name a few common features).  Read more

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3) Why are EHR users replacing EHR SOFTWARE?

 This infographic created for Honeywell depicts the top reasons why hospitals and medical practices are replacing their EHR software. See more

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4) 11 indicators that you need a new EHR

Often so deeply immersed in looking for ways to make their practice more efficient, physicians sometimes fail to see the most obvious hurdle preventing this very process from occurring; their EHR. If your Electronic Health Record (EHR) solution is not up to the mark, you might be losing out on precious profits, and incurring costs that you can easily overcome. Read more

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5) The Convergence of Big Data and EHR Infographic

“In the next 10 years, data science and software will do more for medicine than all of the biological sciences together,” said venture capitalist Vinod Khosla. Data science holds great promise for patient health, but patient data is only actionable in so far as it is digital. Read more

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