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ED Coding and Reimbursement Alert

Avoid the Red:

Understand Your Liability as a Coder

Published on Sun Jun 01, 2003

If you think lawsuits happen only to physicians and hospitals think again. Your code selection determines payment and colors patient records, and that makes you liable for fraud and dishonesty.

You need to understand what the feds consider fraudulent and abusive in coding and what you can do to avoid any hint of cheating the system or patient. The feds aren't out to get you, but they want to ensure every employee in the practice contributes to fair medical care, so you should heed their warnings. Patients too have their health status at stake, so you shouldn't anger them enough to catalyze expensive lawsuits.

Avoid What Smells Like Fraud

Simply put: If your department bills the government for a nonmedically necessary service or for a service your staff didn't render, you along with others can be liable either civilly or criminally, warns Jason R. Levine, JD, a consultant and senior editor for Murer Publications at Murer Consultants Inc., a legal-based healthcare management consulting firm in Joliet, Ill. And you can't hide behind the biller. The coder can be liable for fraudulently reported services even if he or she didn't actually send off the bill, he say.

But your legal responsibility shouldn't keep you from proper coding or reporting expensive or controversial services that deserve reimbursement. Neither CMS nor the HHS Office of the Inspector General (OIG) will seek to label innocent mistakes as fraud and abuse, Levine says. "What they are looking for is a pattern and practice of wrongful activity," he says, a systematic and deliberate practice over a period of time.

You should make sure you understand what raises the feds'eyebrows, so you can cease any potentially fraudulent practices you or anyone else in your department are practicing, intentionally or otherwise. According to Levine, what CMS and OIG consider as red-flag coding practices includes, but is not limited to:

  • Unbundling. Do not unbundle codes for services CMS requires to be coded and billed as one service or item, Levine warns. You can adhere to CMS' bundling guidelines by following Medicare's National Correct Coding Initiative (NCCI) edits. Remember, the edits apply to services billed by the same provider for the same beneficiary on the same date of service.

    When you sift through the NCCI edits, pay attention to code pairs with modifier 0 listed next to them. This indicates that you can never separately report and bill these codes, he says. Modifier 1 means that clinical circumstances may justify appending a modifier for separate payment for the paired codes. You also have the mutually exclusive edit table, which lists pairs of codes you can't report together because a physician cannot reasonably perform them together, he says.

  • Bundling. Though rarer than unbundling, bundling together services into a single code may also result in fraud and abuse, Levine says. For example, when you lump an otherwise unjustifiable procedure into a standard service to warrant a higher reimbursement code, this is a practice similar to upcoding. Let's say your ED physician makes phone calls and partakes in other administrative activities not otherwise billable. If you lump that time spent into a time-based code, you are wrongfully coding.
  • Upcoding. You cannot report procedure or revenue codes that describe more extensive or more expensive work than the physician actually furnished, Levine says.

    One way to avoid fraud if you discover you've made repeated and suspicious mistakes is through the Voluntary Disclosure Program. If you voluntarily disclose your major coding errors to the carrier or commercial payer, you could avoid fines and penalties, but consult with counsel before doing so, Levine says. An instance in which voluntary disclosure might be the ideal route out of problems, for example, may be when you find out your computer system has systematically put the wrong codes for procedures or for place of service, he says.

    Don't Anger Patients

    To incur the wrath of a vengeful patient is not a pleasant experience especially when it involves your pocket book. Avoid patient lawsuits by carefully reporting diagnosis and procedure codes that stay permanently on patient records.

    Patients will sue practices for coding a suspected condition instead of an actual one, and patients will win because the code defames the person and could cause monetary harm by increasing personal health insurance costs, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C., and compliance manager of multiple cardiology groups near Charlotte, N.C.

    One way to avoid misdiagnosing patients is to use signs and symptoms to code the reason for a visit if you lack a definitive diagnosis. If the ED physician orders an EKG (e.g., 93010) for chest pain and you have no definite diagnosis, you should report a diagnosis for chest pain, for example, 786.50 (Chest pain, unspecified), and not a heart attack, from the 410 series (Acute myocardial infarction).

    In addition, you shouldn't assume billing staff knows medical shorthand. If you write "R/O MI" as the medical justification for an EKG, the biller may not know what that acronym stands for (rule-out myocardial infarction) and may pick an incorrect ICD-9 code such as migraine headache (346.0x), which does not support 93010.

    For additional information on coders'legal responsibility, liability and insurance options, read "Medicare Fraud Can You Be Individually Liable?" in the April 2003 Coding Edge, published by the American Academy of Professional Coders.

     

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