Ophthalmology and Optometry Coding Alert

When coders make the same mistakes again and again, the feds could view those benign errors as a malignant attempt to cheat Medicare.

With ICD-9 coding transformed into a fraud-and-abuse risk area, providers must approach the subject with a carefully developed risk management program, said Pat Sevast, consultant with American Express Tax and Business Services in Timonium, Md., in a teleconference.

To safeguard against common coding pitfalls, Sevast offered 10 suggestions:

1. Have access to the rules. Coders must have access to and understand the federal, state and private-payer requirements, Sevast emphasized. The only way to defend yourself against payers looking askance at your decisions is to show that you followed their requirements. And you can do that only if you know what those requirements are.

2. Always base coding on medical record documentation. Be fanatical about reviewing documentation to be sure the record supports the codes selected, Sevast warned. And when you're coding, make sure you have all the patient's documentation in front of you so you can make the proper choices.

3. Keep up-to-date coding reference material. You should use coding books marked "ICD-9 Code Book 2003." Order yours now if you haven't already, she suggested.

4. Run system reports to discover claims with invalid codes. Once new codes take effect, you need to find existing patients with codes that are no longer valid and correct the codes.

5. Never use abbreviated "cheat sheets." Your coding book will help you find the right code, and user-friendly books will make your job much easier, Sevast said. Consulting the alphabetical index, the tabular index and the procedural codes will ensure you comply with coding requirements.

6. Beware of assumption coding. When a coder sees that a patient is receiving a specific treatment or is on a certain medication, it's tempting to assume that "a patient with that medication must have this diagnosis," Sevast said. Then when you review the physician's diagnosis choices, you may want to add the one you just assumed and code it. Don't. First be sure you have a physician's confirmation and adequate documentation for the additional diagnosis, she warned.

7. Never alter documentation. Even if the change "sounds better," if you have a question about the documentation, ask the physician before changing anything, Sevast said. If you need to make changes, document the discussion and follow your practice's protocols for correcting information.

8. Don't bill for services provided by unqualified or unlicensed personnel. Establish procedures to check that everyone has the qualifications they claim to have and that they renew their licenses when needed or you'll be refunding substantial sums to the government.

9. Assign a knowledgeable coder to review all rejected claims. This review needs to be part of your internal coding practices for any claim rejected for a coding issue, Sevast said. Don't just play around with correcting the codes to get them to go through.

10. Protect the confidentiality of ICD-9 codes. These codes are part of the patient record and thus are protect by the Health Insurance Portability and Accountability Act privacy provisions that take effect in April 2003, Sevast stressed.