General Surgery Coding Alert

You might be committing fraud.

Have you ever selected a lower-level evaluation and management (E/M) code than your surgeon deserves because you want to make sure your claims will stand up to an audit? You're not alone, apparently, since national insurer data shows that physicians downcode E/M claims to the tune of more than $1 billion annually.

Let our experts show you three good reasons to stop undercoding your surgeon's E/M services.

You Might Actually Trigger an Audit

If you think that avoiding upper level E/M codes will keep the auditors away, think again.

When claims reviewers look at "bell curves" to determine whether your practice is coding outside the norm, they're not just looking at high-level examinations. Auditors are looking for trends across the board, so a practice with mostly 99212s (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making...) will look just as suspicious as a practice with mostly 99215s (... A comprehensive history; A comprehensive examination; Medical decision making of high complexity).

Truth: Nearly every practice sees more complex patients requiring high level E/Ms at least occasionally. If an auditor reviews your records and determines that you're deliberately downcoding claims, they'll conclude that you've been coding improperly, which may prompt them to look at other aspects of your coding and billing. This has been a focus of the Office of Inspector General (OIG) in the past.

Compliance Cuts Both Ways

If you're deliberately undercoding Medicare or Medicaid claims, you're technically violating the False Claims Act because you are knowingly submitting a false claim.

"It's a violation just as much as deliberate upcoding is a violation, says John B. Reiss, PhD, JD, a health care attorney with Saul Ewing, LLP in Philadelphia.

Caveat: False claims accusations must demonstrate that inaccurate coding is intentional, and the government might be less likely to pursue downcoding cases since it ultimately saves the program money.

Do this: Make sure you know the E/M coding rules and apply them accurately so you avoid downcoding "just to be conservative."

In other words, don't make the following common mistake because you lack coding knowledge and confidence:

"What I'm seeing isn't that physicians are reporting a level one code when they've documented a level five -- they're maybe downcoding one level to be conservative," says Daniel C. Oliverio, JD, who heads the False Claims Act Practice Group at Hodgson Russ, LLP, in Buffalo, N.Y. "In many cases, the doctors are playing it safe because they aren't sure they've met the criteria to report the higher code."

Let's Talk Cash

You may think that downcoding claims is only costing you a small amount of money per year, but "if a practice is undercoding just one level, they're probably leaving a massive amount of money on the table over the course of a year," Reiss says.

Example: If your surgeon's documentation justifies billing a level-four new patient office visit (99204, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity), but you downcode it to a 99203 (... A detailed history; A detailed examination; Medical decision making of low complexity), you've just forfeited about $56.00 (the difference between the two codes based on the national non-facility Medicare rate, conversion factor 34.0376).

If just one surgeon at your practice does this twice a day over the course of a year, you've written off nearly $30,000 annually.

Best practice: Educate your surgeons about how to document thoroughly, and make sure you and other coders select the most accurate E/M code based on that documentation.