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eadun2000

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I have been instructed by a supervisor that if a doctor's documentation does not support the level he billed, then we are to email him telling him why it does not meet the level he wants. Actually, here is what I received "When documentation does not support the provider?s level of service, please send a message to the provider with education on the code they entered and why their documentation does not support that charge. Do NOT change their level. Ask if they would like to make an addendum, or if you should charge the level their documentation supports."

Isn't this ILLEGAL? If it is or even if it isn't, do you know where I can find the supporting information that it is or is not?

Thanks a bunch!
 
It is not illegal to question the level of service recommended. The physician may not be including the elements required to support the code. Medicare offers guidelines E/M services. That is a good place to start.
 
Well in my research, I found this:
"Fraud occurs when someone intentionally misrepresents facts to receive a
benefit illegally. A person who cooperates in a fraudulent situation is also
personally responsible. In a medical office, some of the most common
fraudulent situations include:
? Altering the patient?s chart to increase the amount reimbursed.
? Upgrading or falsifying medical procedures to increase the
amount reimbursed.
? Overbilling primary and secondary insurance carriers while at the
same time collecting payment from the patient."

To me, they are altering the patient's chart to increase the amount reimbursed. They are not altering or amending it because it is missing a procedure note for a procedure that was actually carried out. They are amending it because, say he did not do any ROS and he was coding a 99205. They want us to go back and let them know that all of the documentation except for blah blah blah that was required is missing in order to code that level. Or say he is coding a 99285 and only has 6 systems instead of 8 needed for a complete exam. Those are the things that they want us to tell the doctor so he can go back and amend these charts so they can bill at the higher level. To me, that is fraud.
 
I agree with you. We adjust the E/M code to match the level of documentation, not the other way around. I would also take issue with the supervisor instructing you not to change the OV code; that's what we do, that's why we were hired.

Ask your supervisor what would happen if every provider in that place always put a 99215 and expected you to keep that code AND email the docs 50 times a day. Your practice would not stay open very long - either from the massive audits that would occur, or from all your docs not seeing patients because all they are doing is reading emails
 
it is not fraud to inform the provider that the level of service selected is not supported by the documentation or the medical necessity and request that addition information be documented or the visit level will be changed to match the existing documentation.
I feel it is not correct for a coder to tell the provider what to document as we are not with the patient to know what should be in the note, but to inform them that the documentation is lacking information necessary to support the chosen level is definitely not fraud. of course this must be done prior to submitting the claim.
We need to remember that the providers are human, over worked and stressed and they forget things.
 
We are being told to tell the doctors why the documentation does not meet the level they selected (could be history or examination was epf/detailed and not comp). I have no problem explaining to them that their level of choice is not supported by documentation. However, I DO have a problem with telling them specifically what is lacking and asking them 1. if they want to amend the notes to support the E/M that he has selected or 2. if they want to keep the notes the same and bill the level that the documentation does support. I am a consultant helping a very large hospital system. I have never had to ask a doctor if he wanted to add more documentation to support his level. I have always had the authority to change it to what the documentation supported. Of course if a procedure was done and it was missing the procedure note, then of course we ask for that or even things along those lines. I, however, do not think that we should be telling these doctors what they need in their documentation to support their E/M level.
 
eadun2000 said:
We are being told to tell the doctors why the documentation does not meet the level they selected (could be history or examination was epf/detailed and not comp). I have no problem explaining to them that their level of choice is not supported by documentation. However, I DO have a problem with telling them specifically what is lacking and asking them 1. if they want to amend the notes to support the E/M that he has selected or 2. if they want to keep the notes the same and bill the level that the documentation does support. I am a consultant helping a very large hospital system. I have never had to ask a doctor if he wanted to add more documentation to support his level. I have always had the authority to change it to what the documentation supported. Of course if a procedure was done and it was missing the procedure note, then of course we ask for that or even things along those lines. I, however, do not think that we should be telling these doctors what they need in their documentation to support their E/M level.
Click to expand...


As an auditor and coder I must agree with you; it is fraudulent to alter the documentation to meet a higher level of care. Informing the physician that their documentation does not meet the official guidelines for the specified level of care they assigned is one thing; however, to alert the physician to change the documentation to meet a higher level with the intent to defraud is wrong. And yes, we are human but being stressed or overworked is not an excuse to ignore the rules and regulations set forth in the guidelines. I admire your integrity it is rare.
 
It is not fraud to alert the provider that the "story" they have penned does not "hang together" well and needs clarification. Remember it is medical necessity that drives a visit level. Just because we can document a level 4 or 5 does not me that it SHOULD be done. Therefore if you see a high level assign with not great documentation and a minor problem, I think it is appropriate to alert the provider that something seems to be missing. I do not agree to the extent that this particular manager is wanting to go. As I said we were not in the room so for a coder to tell the provider exactly what is missing is entirely wrong, because in actuality we do not know what is missing only that it does not meet certain criteria. AND even if the documentation does meet a high level, if the problem is minor we must see what does not belong, it is just as wrong for a provider to over document, the level of the medical necessity must match the level of the service provide.
I think you can work around this if you want byt simple indication to the provider that they have assign say a 99214 and give the criteria that must be met for a level 4 such as detailed hx etc, and just state that the documentation provider failed to meet this establish criteria. Or say a patient with sinusitis has no need for a complete pelvic exam, you could message and query as to whether there were any additional diagnosis that would support the need for that that exam. Just because it was done does not mean it gets to count toward the assigned level of care.
So not it is not fraud to query a provider as to the extent or lack of documentation, however we should not be detailing exactly what they need to state to meet a given level of care.
I did not say the being stressed allowed them to ignore the rules, just that they are human and do forget things. Forgetting a key piece of information is way different from ignoring the rules!
 
I thought my saying there is nothing wrong with telling a doctor that their documentation does not support the level they chose and then saying they want us to tell them why and that is fraud would be enough without having to add the rest of the email. Like I said, they are wanting us to tell them what it takes to hit the level that they chose and are wanting us to give them the option to change their documentation. THAT IS FRAUD no matter how you slice or dice it. Here is the FULL email that I guess I should have put on here to begin with:

When documentation does not support the provider?s level of service, please send a message to the provider with education on the code they entered and why their documentation does not support that charge. Do NOT change their level. Ask if they would like to make an addendum, or if you should charge the level their documentation supports. (If you are only changing the code from Inpatient to Observation, do not send an e-mail if it?s just a lateral change.)

Right click on the account in the queue and click ?Defer? for no more than 5 days.

Cc me on the message.

Example e-mail:

Good morning Dr. X,

For Patient Name, MRN, DOS, you entered a 99223, however your documentation does not have a family history or a 10-point Review of Systems. The requirements for a 99223 are listed below:

99223 - 70 minutes (average)
? Comprehensive history. Documentation needed:
? Chief complaint
? Extended history of present illness
? Complete review of systems (10-point)
? Complete past, family, and social history
? Comprehensive examination. Documentation needed:
? General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
? Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
? Extensive number of diagnoses or management options
? Extensive amount and/or complexity of data to be reviewed
? High risk of significant complications, morbidity and/or mortality


Please advise if you would like to addend your note or if I should charge 99221.

Thank you for your time,
Signature

Now that we should be able to see that is fraud as they are amending the documentation for higher reimbursement (and that is fraud), where can I find documentation supporting this?

Thanks for all of your help. It really is greatly appreciated :)
 
I still disagree that this constitutes a fraudulent action or behavior. She is not telling to to instruct the provider on exactly what to document, only that they are deficient in a certain area. This is totally allowable. You are not telling him how to upcode, the provider has documented a note and assigned a level of service, it is entirely possible that in his mind he was documenting all the elements needed for that level, it could be he was distracted by something and it was overlooked. The manager simply wants you to alert the provider that they did not hit the necessary components for that level and you are giving them the choice to document more fully or allow the level to be dropped. I see nothing wrong with this approach and in fact it is more proactive than allowing the level to go out incorrect or dropping the level without the provider knowing or even knowing what they did wrong.
Be careful about using the word fraud for everything you might think is wrong. It is an ugly word and not everything you think is wrong is actual bona fide fraud.
 
We are going to have to agree to disagree on this. It stated in the email that "For Patient Name, MRN, DOS, you entered a 99223, however your documentation DOES NOT HAVE A FAMILY HISTORY OR A 10-POINT REVIEW OF SYSTEMS. The requirements for a 99223 are listed below:" and it goes on to tell him EXACTLY what he NEEDS TO DOCUMENT to SUPPORT 99223 AND we are TELLING HIM EXACTLY WHAT HE IS MISSING. This is JUST AN EXAMPLE. If he was missing 2 elements of his EXAMINATION they want us to tell him that too. There is a huge difference between "just forgetting something" as an every now and then. THIS IS ON ALMOST EVERY SINGLE CHART! FRAUD IS FRAUD. This is fraudulent business practices. You cannot just amend a chart just for higher reimbursement.

You CAN tell them their documentation does not meet the level they chose, however, you cannot coach them to the exact elements that they need to document to get the level they chose and then allow them the opportunity to change it.
 
eadun2000 said:
We are going to have to agree to disagree on this. It stated in the email that "For Patient Name, MRN, DOS, you entered a 99223, however your documentation DOES NOT HAVE A FAMILY HISTORY OR A 10-POINT REVIEW OF SYSTEMS. The requirements for a 99223 are listed below:" and it goes on to tell him EXACTLY what he NEEDS TO DOCUMENT to SUPPORT 99223 AND we are TELLING HIM EXACTLY WHAT HE IS MISSING. This is JUST AN EXAMPLE. If he was missing 2 elements of his EXAMINATION they want us to tell him that too. There is a huge difference between "just forgetting something" as an every now and then. THIS IS ON ALMOST EVERY SINGLE CHART! FRAUD IS FRAUD. This is fraudulent business practices. You cannot just amend a chart just for higher reimbursement.

You CAN tell them their documentation does not meet the level they chose, however, you cannot coach them to the exact elements that they need to document to get the level they chose and then allow them the opportunity to change it.
Click to expand...

Again I will disagree with you. By showing them where the documentation is deficient is not the same as saying" if you add pain, or fatigue then we can count this ...." That would be telling the provider exactly what to document.
OR if the provider had requested a level 3 and documented a level 3 but the coder "coached" the provider on how to obtain a level 4 , THAT would be intentionally trying to get the provider to upcode. The situation you have is a far cry from anything that can be called fraud. However if it makes you uncomfortable and you cannot resolve the issue to both of your satisfaction, then it may be time to part ways.
 
mitchellde said:
Again I will disagree with you. By showing them where the documentation is deficient is not the same as saying" if you add pain, or fatigue then we can count this ...." That would be telling the provider exactly what to document.
OR if the provider had requested a level 3 and documented a level 3 but the coder "coached" the provider on how to obtain a level 4 , THAT would be intentionally trying to get the provider to upcode. The situation you have is a far cry from anything that can be called fraud. However if it makes you uncomfortable and you cannot resolve the issue to both of your satisfaction, then it may be time to part ways.
Click to expand...

Like I stated previously we will just have to agree to disagree. With two others agreeing with me and only one against PLUS what is written by Medicare stating this is fraud, I will definitely agree this IS fraud and take it to the appropriate people. You cannot as a coder tell a doctor that he only has 2 ROS and need 8 more to code a higher code that current documentation does NOT support and give them the opportunity to add 8 more so they can get a higher reimbursement! You can, however, educate them as to why their documentation did not satisfy that higher level so they are aware of it in the future. However they cannot alter the original documentation just to get a higher level. To do so is fraud not only on the doctor's part but on you too.
 
can you provide the link to where Medicare states that this is fraud? And I agree that you cannot tell a provider how to get a higher reimbursement. But that is not what you are saying she wants you to do. The provider is stating he has documented a level 4 you are saying you see only a level 3. I think it is good to alert the provider that he missed the mark by documenting less than the required components. As you stated to tell the provider to coded four more of this and 2 more of that just to obtain a higher level is not correct. That is what I also stated. I think we both want the same thing but i am tempering it by saying it is ok to educate the provider and give them the opportunity to revise the document. Like I said the provider cannot be coached on how to get a higher level when that was clearly not his intent. I did not say they need to alter the documentation just to get a higher level, but they can add an addendum when the level of service documented clearly does not match up to the medical necessity. I guess I just approach it from a different perspective. So we will disagree on this.
 
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