DRG Coding Advisor-Does your coding pose a compliance problem?
Electronic records make it easier to get caught
As the government and payers institute stricter reimbursement policies and electronic medical records make it easier to check for compliance, it's more important than ever for your practice to improve its coding performance. If you're not coding correctly, you could face a government review and stiff fines — even if it's an honest mistake.
Proper coding is important because it's how you communicate what you've done, points out Todd Welter, MSM, CPC, coding consultant for the Medical Group Management Association in Englewood, CO. It's getting easier to get caught if your coding isn't correct. The federal Office of Inspector General and local Medicare carriers are conducting pre-payment and post-payment reviews comparing you with others in your specialty, he says.
"In the government's eyes, if you bill for a 99213 and all you documented was for a 99212, it's the same thing as saying you did four bypass graphs when you did only two. The government looks down on that," he says. "If you do more of a particular code than your peers, they may randomly ask you to send in documentation of some patients. Such a letter is the beginning of an audit."
If you do get a letter requesting more documentation, take it seriously, he adds. "A lot of those letters requesting documentation look benign but they can get doctors in a lot of trouble."
Welter cites three reasons for coding correctly:
• Compliance.
Your practice can prove it provided the services it billed for.
• Reimbursement.
Each code has a dollar figure applied to it. If you code correctly, you'll get the correct amount of reimbursement.
• Statistical analysis.
Coding shows the acuity of your patients. This is important in a lot of managed care situations. You'll need that information if you are going to enter into any kind of capitation arrangement.
Most health plans, including government programs, use the CPT code as a method to determine the payment you'll receive. If you're going to get paid correctly, you have to submit the correct code.
"Although there are a number of software products and tools that can help, there's really no substitute for a good background in coding princi- ples," says Rita A. Scichilone, of Woodbine, IA, practice manager of coding products and services for the American Health Information Management Association in Chicago.
Is your software getting you in trouble?
Coding software sometimes gets physician practices in trouble, particularly if it suggests certain code combinations or tends to maximize billing, Scichilone says. However, other software may have useful segments, such as showing if the CPT code is correct for Medicare coverage or if you have to add additional codes, she adds.
If, in your practice, the physicians check off codes on the encounter form, they should be aware of the rules and guidelines that affect code choices, she points out. "The best situation is to have the physician select the code and the billing and coding specialist validate the code choices to make sure the codes are complete, accurately represent what was performed and what was documented, and [contain no] conflicts with health plan reporting requirements."
She suggests having anyone in your practice who deals with coding attend an educational seminar to make sure his or her skills are up to snuff. Or your practice can hire a consulting firm to review your records and provide one-on-one instruction on coding principles, coding guidelines, and improvement of documentation.
Conduct your own audit
Your practice may decide to conduct its own audit. A good coding review includes checking to see if the documentation meets the criteria laid out for the particular code. Welter suggests compiling a year's worth of utilization data by doctor, broken down by code. Then ask for 10 randomly selected evaluation and management (E/M) notes and accompanying billing forms for each physician. Break the E/M notes into subpieces and compare them with the coding criteria. Look at coding per practice and per physician. If physicians' coding varies from the norm, see whether they have sicker patients or aren't coding correctly.
When Platte Medical Clinic in Platte City, MO, conducted a coding audit, the staff took the physicians' office notes and compared them with what was billed to see if the level of services the physician billed matched the documentation.
In addition to beefing up the practice's coding compliance, the audit discovered the practice was losing revenue because some physicians were undercoding, says Lori Norris, FACMPE, former practice manager at Platte Medical and current physician recruiting and marketing director for North Kansas City (MO) Hospital, which owns the practice.
"I encourage every practice to have it even if it has to outsource. Not only do you need a coding audit for compliance, but you can find a lot of missed revenue," she says.
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