Upcoding investigators are checking out patterns
Sudden coding changes draw attention
You know your hospital isn’t upcoding. But can you prove it?
That’s the situation hospitals around the country find themselves in these days. Federal investigators, including a contingent of hardened former FBI agents, are surveying the health care landscape for any signs of upcoding. And sometimes, simply improving your coding can make your hospital suspect, says Sue Prophet, RRA, CCS, director of classification and coding for the American Health Information Management Association in Chicago.
"I would say that the overwhelming number of coders adhere to coding guidelines, and there have been studies done showing that facilities tend to undercode more than the overcode," Prophet says. But any alteration in your coding practices can show up in data checks by federal investigators.
"Investigators look for sudden changes, either in case mix index or percentage of cases within certain DRGs," says Prophet. "For instance, say the coders weren’t picking up on something that would put more cases into a DRG with complication and comorbidity. If they start picking up on that, all of a sudden their coding is more accurate, but investigators will only see that there was a sudden change.
"I tell people who are concerned about the fraud investigations that they need to look at their own patterns over time, as well as compare themselves with other facilities in their area or with state statistics. If they see any sudden changes or significant variations, they should evaluate that internally themselves to see if they can find the reason. So if they’re ever the target for an investigation, they have the documentation and explanations for the sudden change."
Prophet has these other tips to avoid upcoding sins:
• Be aware of coding changes.
If, for instance, the American Hospital Association’s Coding Clinic the official DRG coding bible announces a change in guidelines or procedures and you did not notice it, you’re still at fault, she adds. Federal investigators only care that the change was published. Make sure your coders have access to these guidelines.
Don’t overlook notices of changes from private insurers and Medical intermediaries, she adds. Often these are sent to the business office, but coders also need the information.
Staying informed is especially critical because there can be slight variations in practices from one intermediary to another.
"What Medicare in Illinois requires may not be exactly what Medicare in Texas requires, which is kind of scary," says Prophet. "So one thing we recommend is that if you have a specific payment policy related to coding from your fiscal intermediary, you need to make sure you keep that documentation."
• Confirm your information.
If you change your coding practices through the advice of a consultant, make sure the advice is supported by official sources. Most coding consultants are legitimate and are dedicated to proper coding techniques, but it’s your hospital that will take the fall if the advice is not found in the regulations.
• Educate your physicians.
Documentation rules are strictly enforced, and physicians hold the key. "Coding consultants can be very useful in this," says Prophet. "A lot of times with physicians it’s the devil you don’t know who’s more successful. The consultant can tell the medical staff the exact same thing the HIM director has been saying for years, but the doctors will only listen if it comes from an outside expert."
• Be careful with expedited coding.
The rush to speed up the billing process can result in coders being asked to work from incomplete medical records. This means investigators looking at records can find that the final
documentation doesn’t match the billing records.
• Watch your case mix index.
Keep an eye on your case mix index and examine the reasons for any increases. "That’s one of the key things the federal government looks for in patterns," says Prophet. For example, Columbia/HCA facilities in El Paso, TX, are being investigated after the case mix index at one facility grew from 1.48 in 1991 to 1.61 in 1995.
Many factors can influence the case mix index, such as new coding practices or even new procedures being performed by the medical staff. But, says Prophet, "Federal investigators see this as a red flag. There are probably perfectly legitimate reasons for it, but you’d better have those explanations in hand before the investigators get there."
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