# Unethical, illegal, or stupid??



## theaterd (Apr 17, 2014)

Being fairly new to coding I would appreciate any help, that anyone can give, or even pointing me in the general direction.

A provider that codes E/M's before they happen.  Fills in the dx codes and the lvl visit code.

Is this illegal?  Unethical?  Stupid?  Perfectly fine?  Or any combination of the 4?

It seems to me at the least it is totally unethical.  How can you know how the visit will go if you haven't seen the patient yet?

Help!??!


----------



## mitchellde (Apr 17, 2014)

There is no way this can be done legally since the codes are based on the documentation and not the other way around.  And what happens if the patient does not show up?  do the charges still get sent?  do the claims go out before the visit occurs?  What if the patient encounter is totally different from what was created prior to the encounter?  and who gets the codes that created prior to the encounter?  It is one thing to write this stuff down it is another thing if the claims are created without a document review.


----------



## RebeccaCross* (Apr 17, 2014)

Just when you think you have heard it all.  How can he possibly do this?  and *WHY*???  I see fraud written all over this...


----------



## theaterd (Apr 17, 2014)

Thank you both for responding!!  It is, as of this writing, unclear whether the provider is only using this as a sort of template, but I will know for sure within a couple hours.
I just don't see how you can code the level before the visit.  It just reeks of fraud.  
Again, thanks for responding so quickly.
My respect for that provider has been destroyed.  And I thought she was one of the good ones...


----------



## theaterd (Apr 17, 2014)

Well, the jury is in.  The levels on all 3 patients I checked and printed before the patient's appt., match exactly to what "actually" occurred at the visit.  

Disappointed.

I am not looking forward to the s#*t storm that's coming...


----------



## RebeccaCross* (Apr 17, 2014)

Have you spoken to anyone/provider about this "method" (wink-wink) of coding. It sounds as if the patient's are asked to come in for the sake of getting something in return...


----------



## MnTwins29 (Apr 17, 2014)

Wow - Rebecca said my thoughts exactly.  Although I do want to say that I wouldn't be "disappointed" by the fact that the first three patient records you checked were correct - that is quite a small sample.   

Wondering if this is a template for the same type of visit/encounter for each patient?  Meaning, yes, each patient that is coming in for treatment of ____ will have this done and it will be code 9921x.   Which if not fraud, would make me wonder about the type of treatment the patient is receiving....


----------



## mssalemny (Apr 17, 2014)

I have been coding and auditing for over 20 years. I have to say this is definitely a new one. I would tread careful and follow through with investigating this. There may be more to it then you expect and certainly you will want to document everything you find. Just to play devil's advocate, and in no way do I support starting charts prior to patients coming in, but consider that the provider may be trying to save time by starting charts ahead of the visit. If that is the case, the provider may not even realize it is a problem. But no matter what the case was, due diligence is necessary here when investigating. Good Luck !


----------



## MarcusM (Apr 17, 2014)

I would start your own audit trail with E&M coding sheets that CMS offers:
http://www.cms.gov/site-search/search-results.html?q=evaluation and management guidelines
and re-educate your provider. It may be that her experience is pretty accurate for coding, but to save time by pre-marking the billing is just wrong....


----------



## theaterd (Apr 18, 2014)

Again, thanks to everyone for your comments!  I checked her NP schedule for today, and this person has every single bill already filled out with dx's and E/M codes.
As has been said already, it's possible they are using these as a template.  However when I spoke to my boss she was pretty adamant that this was fraud.  And that these providers are walking into the visit knowing they have to "meet" the level they have already coded.
I will continue to monitor, and document, as has been suggested.  These providers are from a separate office and I'm not sure how long to wait before I talk to the Practice Manager.


----------



## theaterd (Apr 18, 2014)

Thanks, MarcusM for the link.  Very helpful!!


----------



## MsGarner69 (Apr 18, 2014)

I'm curious to know what does she do if the patient doesn't show or comes in with a different diagnosis then she's assuming. Does she simply throw the bill away and start a new one to reflect the "actual" diagnoses? Or leaves the bill as is with the fraudulent information? Would it be legal for you to copy the "pre-filled" bills and keep them for yourself as additional documentation you might need to validate your claims?


----------



## theaterd (Apr 18, 2014)

MsGarner69 said:


> I'm curious to know what does she do if the patient doesn't show or comes in with a different diagnosis then she's assuming. Does she simply throw the bill away and start a new one to reflect the "actual" diagnoses? Or leaves the bill as is with the fraudulent information? Would it be legal for you to copy the "pre-filled" bills and keep them for yourself as additional documentation you might need to validate your claims?



Funny you should bring that up.  She had 2 no shows so far today, and the superbills are still showing all the codes the NP put in ahead of time.  The only difference is that up in the corner of the superbill it says "no show".
To your other point, I am printing these superbills, both before patient, and after patient, or after the no show.  
Because the codes are still in there, I really get the feeling that these aren't intentional fraud, but that isn't my decision to make.


----------



## mitchellde (Apr 18, 2014)

hmmm I feel a full scale audit is in order to review all past billings this does not sound at all good, intentional or not.


----------



## MsGarner69 (Apr 18, 2014)

theaterd said:


> To your other point, I am printing these superbills, both before patient, and after patient, or after the no show.



I think that's a good idea, because if the _no show_ is reflecting any codes at all as if the patient was actually seen that thats a problem...a BIG one. My concern also would be how would you be able to determine if she's coding them correctly after they were seen if her documentation is "adjusted" to make her own MDM fit whatever code she wants it to?


----------



## theaterd (Apr 21, 2014)

I need to know if ANYONE knows if, "pre-coding a visit is illegal, or unethical", is written down ANYWHERE in black and white so that when I have to approach these folks they can't say they're doing nothing wrong.


----------



## RebeccaCross* (Apr 21, 2014)

*Recommended link...*

http://oig.hhs.gov/authorities/docs/physician.pdf

I would start here and develop a compliance plan for your practice(s)...


----------



## theaterd (Apr 21, 2014)

Thanks for the link, Rebecca!

Unfortunately, after extensive research, I have not found any written rule or law that prohibits what these providers are doing.  As long as the note is accurate when it is signed, and the superbill reflects the correct charges based on the note, it's all good.
The best I could find is this link;
http://www.fortherecordmag.com/archives/031411p14.shtml

it has some best practices.


----------



## mitchellde (Apr 21, 2014)

Look in the federal register, this is a time consuming activity and you need to use different search words, however I do remember seeing a passage that stated only AFTER a review of the documentation can the codes be selected.  I used this passage years ago in a court case and was very successful, but that was several years back and I do not have access to that resource file at the present time.  
I was using this as a case against a billing service coding only from superbills and incorrect codes were being selected when they had contracted for coding and billing.  It should work for your purpose as well, I just do not remember which section, but I looked for days until I located exactly what I needed.


----------



## bethdeak (Apr 23, 2014)

I guess my thinking is along the lines of:

If the patient complains of fever and runny nose prior to the visit, and that gets plugged in 'in advance' and the patient is diagnosed with a sinus infection after the exam- is the initial complaint of fever runny nose listed instead of the diagnosis of sinus infection?

Something like that would be against the general coding guidelines especially if a definitive diagnosis has been established.


----------



## theaterd (Apr 24, 2014)

I wanted to thank everyone that responded.  Again, your help was much appreciated.
I talked to management and they are taking this very seriously.  I know that the lawyers will be involved and that is what I wanted in the first place.
I'm confident that after an internal investigation they will take appropriate action... and of course I'll be watching...just in case.


----------

