Pediatric Coding Alert

Find the trouble signs before they turn into disasters

When you're auditing your charts, will you know how to recognize the signs of a major problem? Here are some red flags our chart-auditing experts have come across:
 
 
1. Billing the same code again and again. If all of your patients are level four or five, you've got trouble, but the same is true if they're all level two or three, says consultant Maxine Lewis with Medical Coding Reimbursement Management in Cincinnati.
 
2. Hospital admissions. Often, physicians don't understand how much documentation they need to provide to justify a hospital admission. You need a comprehensive history and a comprehensive examination to justify a level-two or -three hospital admission, and one of those is often missing, says Barb Pierce, coding and reimbursement director for Professional Management Midwest in Omaha, Neb.
 
3. Consults. Now that the rules for consults have recently changed, you need to make doubly sure you have the request for a consult documented in your files and in the requesting physician's files.
 
4. Canned documentation. If you have a template that you use for visits, make sure your pediatrician doesn't just keep reusing the same answers. If a patient comes in with chest pain, and the doctor has already checked the box that says "no chest pain," it won't justify the work your physician did, Lewis says.
 
"People need to be cautious about cutting and pasting, and having too much canned documentation," Pierce says.
 
5. Illegible documentation. If the auditors can't read your pediatrician's writing, they won't bother to audit the chart -- they'll just throw it out,  Lewis says.
 
6. Blank documentation. You choose an x-ray code by the number of views the physician performed,  Lewis says. But often a physician will leave the number of views blank, and an auditor will downcode that claim to two views, the minimum amount, she adds. Also, she audited some physicians who failed to document when they did a urinalysis, so they were losing money every time.
 
7. Tests documented but not done. One physician couldn't produce the report on an x-ray or even its results. In an audit, Lewis found that 60 percent of the x-rays the physician ordered weren't happening because the patients were leaving without having them. His chart showed that he'd ordered the x-ray, but there was no follow-through. Lewis helped him come up with a system to make sure the patient actually had the x-ray after the physician ordered it.
 
8. Time-based coding. If you're billing for counseling and coordination of care, you're entitled to bill based on time, if the time spent counseling and coordinating care constitutes more than 50 percent of the designated encounter time. But you should make sure the physician has documented the time spent with the patient, and how much of it was counseling or coordination, says Valerie Thompson, a consultant with Gates Moore & Company in Atlanta.
 
9. Teaching physicians. Pierce still sees charts in which the teaching physician has written "Agree with above" after the resident's documentation. CMS has clarified that the teaching physician has to write something more positive indicating that he personally saw the patient.
 
10. Undercoding. If you're undercoding all of your visits, that's just as illegal as overcoding, Thompson says. "You have to code per what's documented."