Wiki Possible Fraud

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kpnyc@sbcglobal.net

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Hi,

I recently started a new coding position at a small independent Neurology clinic and wondered if I could have help regarding what I’m finding to be questionable coding.

The clinic is seeing mostly ADD and AD/HD patients. They have told me that by coding these diagnoses as primary, they will not be paid for the visits. Therefore, they code R27.9 unspecified lack of coordination as primary always. The problem is that as I read the reports, some do not document this diagnosis at all. The coder training me let me know that she does not even read the reports when choosing the diagnosis codes.

Is this fraudulent? And if so, is there another code that can be used that would be accurate and can be billed to insurance? Any help would be greatly appreciated as I am determining whether to keep this job. Thank you!
 
As a new coder in a new position, please always assume positive intent before your throw around the 'f' word. Your job is to correctly code the services as they are documented. The provider is obligated to act according to the scope of their licensure and provide the most appropriate assessment of the patient. Sometimes it takes a number of visits/test/evaluation appointments to arrive at a diagnosis code, and if that information is provided by another clinician, your clinician is well within their scope (and right) to assess differently, as long as their own documentation can support it.
In your circumstance, however, if the documentation that corresponds with the charge that you are submitting for payment does not support the diagnosis that is being provided, and the reason that they are doing this is simply to secure payment, then indeed you may have the opportunity for a conversation. Coding for a condition that the patient does not have is a violation of the False Claims Act. Submitting a payable code when a non-payable code more accurately supports the patient's condition is a violation of the False Claims Act. Reporting a symptom when a more specific condition exists is inappropriate coding per the ICD-10-CM guidelines. Because this is a small independent private practice, I am going to bet that they are struggling to keep the doors open, don't realize they are potentially going to land in hot water, are being dishonest with regard to patient care, and don't have the faintest idea about compliance. Rather than blow the whistle, maybe you could sit down with them and determine why they think that ADHD isn't covered. (From personal experience, most payers will cover, but you often need to follow the payer guidance).
You have a golden opportunity to be the hero here, sort this practice out, and get them to a point where they are both compliant and solvent. Good luck.
 
KPnyc:oops:
Pam Warren gave you good advice! You must read the medical documentation and assign dx code what the dx states by the expert provider. Evidently the dx R27.9 will be rejected by payers and this could cause the practice to lose funds but to bill the patient since they pay premiums to cover it. Select dx code on what is the patient s problem & assessment is given. If it comes down to fraud you will be blamed not reading & coding what is in the documented in medical record. Now if all the provider gives you is dx R27.9 only he or she will be blamed. There is wide variety of dx codes to use if relates to patient s condition but it must be documented...gait, cramps and spasms M62, R29, R25 Tremor Ataxia ,I69.3 ,Stiffness M25.61 of body areas, Joint Instability M25.3 G25 History of Falling Gaits R26 vs R26.81 Vertigo R42 T84 Breakdown of Implant Orth devices, Z74 Reduced mobility .Check out mental health dx blocks of F44.4,F98.4,F30 ,F20 ,F43 or substance abuse it fits psyche patients' problems see dx blocks Z13.49, Z13.858, Z13.39 as last dx claim where it fits medical story of patient.
If management fusses show them the ethics of medical coders must code what is documented
I hope helped you:)
Lady T
 
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