Pediatric Coding Alert

To avoid fraud and abuse charges, pediatric practices should follow the recently released guidelines of the Office of the Inspector General (OIG) for individual and small group physician practices. Although the guidelines relate to Medicare, private payers as well as Medicaid are adopting Medicare's compliance policies. Therefore, pediatricians need to be aware of OIG rulings.

What are the greatest risk areas that the OIG has determined in terms of fraud? There are four and coding and billing tops the list. They include:

coding and billing,
reasonable and necessary services,
documentation, and
improper inducements, kickbacks and self-referrals.

Pediatricians should start with these items when reviewing their practice for vulnerabilities. The objective of such an assessment should be to ensure that key personnel in the physician practice are aware of these risk areas and that steps are taken to minimize, to the extent possible, the types of problems identified, the guidance states.

Correct Coding and Billing

Pediatric practices need to watch for the specific risk areas associated with billing summarized in the OIG draft guidance. These areas have been frequent subjects of investigations and audits by the OIG:

Billing for items or services not rendered or not provided as claimed;

Submitting claims for equipment, medical supplies
and services that are not reasonable and necessary;

Double billing;

Billing for non-covered services as if covered;

Knowing misuse of provider identification numbers;
which results in improper billing;

Billing for unbundled services;

Failure to properly use coding modifiers; and

Upcoding the level of service provided.

The OIG states that your written policies and procedures about coding should reflect the current reimbursement principles set forth in applicable statutes, regulations, and federal, state or private payer health care program requirements and should be developed in tandem with coding and billing standards used in the physician practice. This is a tall order, especially when the rules for coding for Medicaid, for example, can differ so widely from the rules of coding for private managed care organizations and indeed, when managed care organizations frequently have their own individual coding rules. But, there are two factors to make this easier:

1. All coding and billing should be based on medical record documentation, so the better you are at documenting, the safer you will be regardless of vagaries of individual payers; and

2. Diagnosis codes can help point to the correct procedure code, [...]