Part B Insider (Multispecialty) Coding Alert

Published on Fri Oct 02, 2009 PDF

Examine claims for odd activity, experts say.

With compliance in the spotlight, many coders are on high alert. Know what to do if you come across a questionable claim.

President Obama has made it a priority to curtail Medicare fraud, and major media outlets including 60 Minutes have recently profiled this growing problem. The increased attention on staying compliant has caused medical coders across the country to check and double-check their physicians' documentation to detect issues.

The OIG has issued scores of documents that profile the types of fraud that they are investigating. For instance, last week the OIG released its "Health Care Fraud and Abuse Control Program Annual Report for FY 2008."

For instance: The OIG sentenced a physical therapist to six months of incarceration for work that wasn't performed -- in fact, the PT "submitted claims that would have required working more than 15 hours a day, and often more than 24 hours a day, for more than 600 days," the report indicates.

Take action: If you notice that your provider has billed an abnormal pattern as the PT in the example did, check the documentation to confirm that you're billing the appropriate codes that match the services performed and recorded.

"Take a look at the documentation -- maybe there is a discrepancy between coding and documentation that might explain the issue at hand," advises Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, with ComplyCode in Binghamton, N.Y. "For example, if the therapist only performed one unit of a 15-minute service, but accidentally marked four on their charge ticket."

If the documentation supports the billing but the coder knows that the therapist didn't work 18 hours that day, the coder should approach her manager or compliance officer, Harrington advises. "Hopefully there will be a simple answer to the situation -- that it truly was a mistake, or something to that effect."

You can't always count up a physician's hours the same way you could count a physical therapist's or other provider who mainly bills time-based codes.

For instance: If you review claims for E/M codes, you can't assume that the physician will meet the time benchmarks in CPT during every visit.

"In some cases, the doctor isn't billing based on time but still meets  the requirements of the E/M code,"says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPCP, CENTC, CHCC, president of CRN Healthcare Solutions. "A 99214 visit may take 15 minutes even though the code says it should typically take 25 -- unless counseling or coordination of care took up at least half of the visit, you won't be coding based on the time anyway, so if the documentation and the nature of the presenting problem back up the code choice, you can report it," Cobuzzi says.

Consider this: In some cases, the OIG might say that it's impossible for a physician to perform a certain number of visits in a single day but that you've submitted claims implying that he did. "Remember that a doctor might look like he's doing more than he did because two or three non-physician practitioners could be billing incident to and it looks like the doctor did three times the amount of work a physician could do in a day," Cobuzzi says.

If you do find fraud: In some cases, you might review the documentation and find that your provider did bill improperly. "If a coder knows of an issue and hasn't made an attempt to resolve it, they could potentially be implicated, and would at a minimum be in violation of the code of ethics of whatever professional organization gave them their credential,"

Harrington says. "At maximum, they could be seen as an accessory to the fraud (that would obviously be quite extreme)." "Let your conscience be your guide," Harrington says. If you see a potential issue that you can't resolve, check with your manager."