Practice Management Alert

Undercoding is just as problematic as overcoding, an expert says.

The prior authorization process can be frustrating and time-consuming, and some practices may feel like they’re saving everyone time and money if they seek prior authorization — and code — only what they know for certain will happen in an encounter.

However, coders should prioritize accuracy above all else, especially because inaccurate reporting — even if it seems to save people money — can cause lots of headaches, including enforcement actions by federal agencies looking to cut down on fraud, waste, and abuse.

Consider The Circumstances of This Encounter

Picture this: A patient at your practice requires an endoscopy, and you seek and receive prior authorization for the service. While the provider is performing the endoscopy, they realize that the situation requires a biopsy — for which no one sought prior authorization. If you code this situation according to the prior authorization, are you undercoding the encounter?

Let’s say you did just code the endoscopy, but then the patient’s biopsy comes back positive for cancer?

Now the patient needs more surgery, more inpatient or other facility stay, but there’s no record for a biopsy even though you have a pathology report, which doesn’t match what was reported by the surgeon or physician, says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California. This could lead to a payer inquiry: How did you find out the patient had cancer from an endoscopy alone? How did you come to have a pathology report?

Know That Undercoding Can Be Fraudulent

The scary f-word in healthcare is fraud, which the Centers for Medicare & Medicaid Services (CMS) defines as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”

So, if fraud is the intentional misrepresentation of codes, then coding just an endoscopy even though a biopsy was performed could fall under that umbrella. The falsification was an innocent mistake but nonetheless representative of medical coding errors that fall into the category of fraud and abuse, Fletcher says.

Prioritize Accuracy Above All Else

As a coder, you know that your efforts do a lot to dictate a patient’s narrative of health and illness; you provide an official record of their condition. Therefore, making sure your code choices reflect the patient’s specific situation is crucial for myriad reasons.

“It’s important to make sure that we code accurately. Downcoding, undercoding, trying to capture it just for money is wrong. You may find yourself in a really compromised situation,” Fletcher warns.

Of course, coders who intentionally undercode may think they’re doing something helpful, either by avoiding expense for a patient or a payer or trying to avoid a mistake made in a prior authorization.

“I don’t think a lot of people think about fraud, waste, and abuse as undercoding, because they think they’re saving money for the payer — but even if you are, you aren’t doing yourself a favor by reporting things incorrectly,” Fletcher says.

Bottom line: Make sure your code choices are accurate. “We can’t do things just to get paid, we have to do things correctly,” Fletcher says.