Skirt the upcoding spotlight
Maximizing is OK, but substantiate
Any abrupt shift in coding or billing practices could put your facility in the crosshairs of fraud investigators. You know it’s illegal to code for diagnoses that are not substantiated, but where do you draw the line between maximizing and optimizing?
Quality managers (QMs), whether they’re serving in the role of compliance officer or not, need to be aware of the quality monitoring procedures that are in place within the coding processes. Maximi zing reimbursement is always the goal, and with the proper documentation, it is legal to code in order to receive the maximum payment allowed.
Upcoding is the practice of illegally using medical reimbursement coding to increase third-party payments. The difference between illegal and acceptable coding practices can be a gray area, and the professional ethics of medical record coders are continually challenged. It is the QM’s job to ensure they don’t fall into traps that can result in unintentional lapses.
Sue Prophet, RRA, CCS, director of classification and coding at the American Health Information Management Association in Chicago, recommends the following strategies to ensure your facility’s coding doesn’t cross the line into impropriety or give the appearance of it:
• Make sure all coding staff have been properly trained and receive continuing education.
• Develop and update comprehensive internal quality policies and procedures for coding and billing.
• Conduct random, periodic reviews to make sure procedures are being followed.
• Monitor coding accuracy through quality audits.
• Compare diagnosis codes with procedure codes for consistency.
• When documentation deficiencies are identified, educate the physicians on improving their documentation.
• Keep up to date on government regulations.
• Compare your facility’s DRG distribution with national data.
• Evaluate claims denials and code and DRG changes from the fiscal intermediary and state Peer Review Organization.
• Examine your organization’s data over the past several years. Have there been any significant changes in case mix or coding practices? Keep in mind that any sudden changes in patterns can raise a red flag in the minds of the authorities, and fraud investigations can go back several years.
• If you identify an inappropriate coding or billing practice that could be construed as fraud (i.e., it resulted in overpayments), inform your legal counsel.
Recommended Reading
Prophet S. Fraud and abuse implications for the HIM professional. J AHIMA 1997; 68:52-56.
Coding in the anti-fraud era
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