ED Coding and Reimbursement Alert

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 [...]