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Pediatric practices need to watch for the specific risk areas associated with billing summarized in the OIG draft guidance.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, again bearing in mind that documentation must support both kinds of codes.

OIG states that every practice should have the coder review all claims that are rejected for diagnosis or procedure codes. This should facilitate a reduction in similar errors, the guidance states.

Document Properly

Pediatricians should pay extra attention to documentation. The OIG guidance calls documentation of diagnosis and treatment one of the most important physician practice compliance issues. Documentation must be timely, accurate and complete, the guidance states. It is the basis for coding and billing. It also facilitates quality patient care by helping to ensure accurate recording and timely transmission of information, according to the guidance.

But you know what documentation really does. It tells what work was done. In the words of the guidance, the medical record can be used to validate the following:


the site of the service,

the appropriateness of the services provided, and

the accuracy of the billing.

Below are the principles of accurate medical record documentation, according to the OIG:

The medical record should be complete and legible.

The documentation of each patient encounter should
include the reason for the encounter; any relevant history; physical examination findings; prior
diagnostic test results; assessment, clinical
impression, or diagnosis; plan of care; and date and legible identity of the observer.

If not documented, the rationale for ordering diagnostic
and other ancillary services should be inferred easily by an independent reviewer or third party.

Past and present diagnoses should be accessible to
the treating and/or consulting physician.

Appropriate health risk factors should be identified,
including the patients progress, his or her response to and any changes in treatment, and any revision in diagnosis.

All CPT and ICD-9 codes reported on the health insurance claim form should be supported by documentation in the medical record, OIG states. In addition, pediatricians must be clear as to who provided the services. These issues can be the root of investigations of inappropriate or erroneous conduct and have been identified by the Health Care Financing Administration (HCFA) and OIG as a leading cause of inappropriate payments, the OIG states.

Filling Out the HCFA 1500 Claim Form

Properly completing the claim form is an important part of proper documentation. Here are the practices recommended by OIG to make sure the form is completed correctly.

Link the diagnosis code with the steps taken to
perform an examination and the record of personal
history obtained.

Link a single most appropriate diagnosis with the
corresponding procedure code.

Use modifiers appropriately.

Why You Need a Compliance Program

In light of the release of the OIG guidelines, many pediatric practices need to seriously consider instituting a compliance plan. For many pediatric practices, coding compliance has not been as significant as conforming to whatever rules the managed care companies they participate in have made. Medicare is a very small, or nonexistent, part of a pediatric practice. When pediatricians hear about documentation guidelines for evaluation and management (E/M) services codes, for example, they sometimes wonder, Who cares? But the fact is that Medicare rules are permeating managed care organizations and, as this guidance shows, provider practices.

It makes good business sense to develop a compliance plan, says Richard H. Tuck, MD, FAAP, founding chair of the American Academy of Pediatrics Committee on Coding and Reimbursement, and in practice with PrimeCare Pediatrics in Zanesville, Ohio. It also makes good sense medically, he says, adding that Good documentation is part of good medicine.

For pediatricians who are worried that they are behind in this, dont be. First, youre not alone. Second, the OIG doesnt expect everyone to do everything.

The OIG recognizes that full implementation of all elements may not be feasible for all physician practices, the draft guidance states. However, as a first step, a good faith meaningful commitment to compliance will substantially contribute to the programs successful implementation.

Larger practices can be systematic about addressing each of the elements in the OIGs plan. Smaller practices, however, should consider addressing each of the elements in a manner that best suits the practice, the draft compliance guidance states. One general recommendation is that all standards and procedures be in writing in the practice, with lines of responsibility clearly delineated.

Policies should be set up to prevent fraudulent or erroneous billing. Many non-pediatric practices already have some kind of safeguards because they have been dealing with Medicare audits. In addition, virtually all hospital-based practices including hospital-based pediatric practices are well acquainted with compliance because there are hospital compliance departments. The OIG encourages collaboration with hospital compliance departments but recognizes that individual and small group practices have their own needs.

Finally, you need to develop a compliance plan because it is going to help you if you get audited. We are working on developing one now, Tuck says, noting that his office is working with a local attorney who is assisting.

Weve come to a time when you are required to document all services that you provide, says Ricardo Garcia, CPC, CEO of DRG Associates Consulting Group, a Denver, Colo.-based coding and reimbursement consultant who does billing for 750 physicians, including 200 pediatricians. Garcia, formerly supervisor for physician billing at Childrens Hospital in Denver, uses the 1997 E/M documentation guidelines. I have templates for the pediatricians to use, and that makes it a lot easier, he says.

The templates that were released by HCFA were not very useful for pediatrics, Garcia felt, so he created his own. For example, we needed head circumference, he says. And a lot of times, you have to use the mother for the history.