Medicare Compliance & Reimbursement

Question: I’m a new hire at a practice that primarily sees patients concerned they have attention-deficit disorder (ADD) and/or attention-deficit/hyperactivity disorder (ADHD). My boss said that they can rarely get claims paid when the primary diagnosis is ADD or ADHD, and so all the coders for the practice should code R27.9 (Unspecified lack of coordination) as the primary diagnosis so our practice gets paid. When I’ve looked at patient records, I haven’t seen this “unspecified lack of coordination” anywhere. This makes me uneasy, but I don’t know that it’s officially “wrong.” Does my boss’s coding directive go against any guidelines or regulations?

AAPC Forum Participant

Answer: The ICD-10-CM Guidelines direct coders to code to the most specific diagnosis documented, rather than signs and symptoms, when possible. If the documentation for a patient does not mention the sign “unspecified lack of coordination” but a coder relies on this descriptor to select an ICD-10-CM code for primary diagnosis, then it would appear that the coder is coding a condition that the patient does not have, which, if the patient is covered by Medicare or Medicaid, is a violation of the False Claims Act (FCA).

According to the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), one does not need to intend to defraud the government to get in trouble over the FCA: “Under the civil FCA, no specific intent to defraud is required. The civil FCA defines ‘knowing’ to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information. Further, the civil FCA contains a whistleblower provision that allows a private individual to file a lawsuit on behalf of the United States and entitles that whistleblower to a percentage of any recoveries. Whistleblowers could be current or ex-business partners, hospital or office staff, patients, or competitors.”

If your boss genuinely does not understand the ICD-10-CM coding guidelines, this could be an opportunity to provide some education.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC