General Surgery Coding Alert

Make sure surgeons document medical necessity.

You can keep your surgical practice out of the Fed’s sights if you adhere to a few simple guidelines.

Read on to see what experts have to say to help you file claims that the Office of Inspector General’s (OIG) can ignore.

Tip 1: Ensure Thorough Documentation

If you keep pristine documentation, you’re way ahead in the compliance game. “You want to make sure your medical notes are legible, make sure every entry is signed and dated, and you’ve probably heard this before, but if a service is not documented it is not done,” said Lori Langevin, National Government Services (NGS) Medicare representative during a recent webinar on fraud and abuse.

To demonstrate medical necessity, your documentation should also accurately report diagnosis codes, and precisely reflect the work provided, avoiding “upcoding” to a higher level of service. Most upcoding is due to insufficient documentation, not due to clinicians “padding their invoices” for better reimbursement, according to Jan Blanchard, CPC, CPMA with Physician’s Computer Company (PCC) in Winooski, Vermont.

Caution: If your documentation does not demonstrate medical necessity for the procedures provided, your practice could be in hot water. The OIG has prosecuted cases that resulted in prison time and million-dollar settlements for medically-unnecessary treatments.

Remember, Medicare defines medically necessary services as “healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” And the best way to demonstrate medical necessity is with thorough and accurate documentation. “If the medical record does not support the service(s) billed, CMS can certainly recoup the funds paid to the provider,” explains attorney John E. Morrone, a partner at Frier Levitt Attorneys at Law in New York.

Tip 2: Always Collect Deductibles and Copays

“You can’t routinely waive deductibles and copays,” Langevin said during the webinar. “It’s unlawful because it can result in false claims, can violate the anti-kickback statute, and is considered excessive utilization of items and services paid for by Medicare.”

Of course, there will always be instances when you spend hours trying to collect, and patients simply won’t pay, but the NGS rep had advice for that situation as well. “What we like to say is, as long as you make a good faith effort to collect deductibles and copayments from your patients and you document your efforts in the patient’s medical records, then you wouldn’t really have to worry about this issue, but there are some practices that, believe it or not, routinely waive so they can get the business,” Langevin said. “Those practices will say, ‘Come to our office, we’re not charging copays.’ You can’t do that as a Medicare provider. That’s a violation.”

Tip 3: Monitor EHR and Billing Service Performance

You may think your billing service is just as capable as your in-house coding and billing staff, but that doesn’t mean you should skip oversight. “Pay attention to your billing services’ practices; make sure they’re keeping accurate, complete administrative records of the claims that they submit on your behalf,” Langevin advised. “Instruct the service not to change your codes, procedures or diagnoses, as well as other information furnished by you.” Errors made by the billing service do not relieve your surgical practice of responsibility.

Similarly, your computer and electronic health record (EHR) is not beyond the need for human oversight. “EHRs can automatically bump your codes to a higher level, so keep on top of that common problem,” suggests Chip Hart, director with Physician’s Computer Company (PCC) in Winooski, Vermont.

Tip 4: Act Quickly If You Did Something Wrong

If you think you’re in a problematic relationship or you’ve been using billing procedures that you discover are wrong, immediately follow the steps below, said NGS Medicare’s Gail O’Leary during the webinar:

• Seek legal counsel.
• Stop filing using the problematic methods.
• Find out if you collected any money in error.
• Take any steps necessary to free yourself from involvement and from any suspicious relationships.
• Consider using self-disclosure protocols set out by CMS and the OIG.

Providers have to report overpayments within 60 days after they have been identified, but accepting voluntary refunds from providers does not limit the government from taking action to pursue any remedies, O’Leary added.