AAPC - credentialing the business side of medicine

StephSH · #1 01-06-2012, 01:07 PM

Hi All,
We've got a Dr who is coding a lot of 99215s and we've been changing them to 99214 or 99213 based on documentation. He has stated that "per CMS Guidelines NO ONE but the physician is allowed to change a code". Now we know that we are here to code and all of that, but we need to know WHERE does it say we can change a code? Our manager just got let go, so we need to know how to respond to him with proof of our own. It is not a situation where we can go to him and ask where he sees that we cannot change it either.

Can someone help us out here? We're Googling like crazy and cant find what we need to support that we are supposed to code correctly.
Thanks

kevbshields · #2 01-06-2012, 05:09 PM

What he might be referring to is that providers are ultimately responsible for the codes the submit for reimbursement. However, it's a leap to say that prevents "anyone" from changing his codes.

If the codes the provider selects are inappropriate, they should be changed.

Now that does not address the issue of provider education. Perhaps you would not have to change his codes if he better understood the E&M guidelines. Given your reference to a manager being "let go", step carefully. I'd consider working with the provider on cases where you disagree with the E&M he reports. Treat it like a teaching approach. He is going to "teach" you how he arrived at that code. Of course, bring along your guidelines, audit sheet and the note. If you still do not agree, or he simply cannot justify his levels, show him what you have found to be true from the guidelines. The best approach is probably to get his "take" on what those guidelines mean.

I'd document that the session was held and the topics discussed. Some providers come around and some insist that what they know is true and what you know is false. Either way, you've done your part and need to decide how to proceed after that. It's a difficult case to deal with; if you have a compliance officer, the results of your engagement with the provider will determine if you need to approach him/her.

wassock · #3 01-07-2012, 09:48 AM

You are not just in the business of coding. Part of the job involves keeping you providers compliant. If you tell him/her that when, not if, they are subject to a RAC audit, MCR will surely take money back for inappropriate level 5 visits. For a start, if they are all level 5 then a huge red flag is raised and they will be on him.
One of my group of physicians were tired of me directing them on how important accurate documentation needed to be in order to bill a certain level. They have now been subject to a RAC audit and are, 1) eternally grateful for what I told them, and 2) insistent that I maintain the high standards and code everything to the level I feel is appropriate. After all, not every visit can be a level 5. MDM is the overarching factor in determining a level of service. That is the deciding factor, not how many bucks can I get.
You may point your provider in the direction of E&M university where there is a lot of information, much of which is free.
You are certainly entitled to change a level of service, if only for the reasons I've stated. It is not illegal; fraud and abuse are.

theresa.dix@ethc.com · #4 01-09-2012, 03:30 AM

Quote:

Originally Posted by wassock

You are not just in the business of coding. Part of the job involves keeping you providers compliant. If you tell him/her that when, not if, they are subject to a RAC audit, MCR will surely take money back for inappropriate level 5 visits. For a start, if they are all level 5 then a huge red flag is raised and they will be on him.
One of my group of physicians were tired of me directing them on how important accurate documentation needed to be in order to bill a certain level. They have now been subject to a RAC audit and are, 1) eternally grateful for what I told them, and 2) insistent that I maintain the high standards and code everything to the level I feel is appropriate. After all, not every visit can be a level 5. MDM is the overarching factor in determining a level of service. That is the deciding factor, not how many bucks can I get.
You may point your provider in the direction of E&M university where there is a lot of information, much of which is free.
You are certainly entitled to change a level of service, if only for the reasons I've stated. It is not illegal; fraud and abuse are.

Seems your physician does not have much trust in the coders? I suggest you have an outside auditor review some of his documentation and provide education to the physician. Sometimes that is what it takes.

mdoyle53 · #5 01-09-2012, 05:31 AM

There is no official documentation about changing the code assignment. The MD is the one who is responsible and whose name is on the claim so they are ultimately responsible for the code assignment. Here is an article that basically states this: http://www.ingenix.com/content/attac...icle_dec01.pdf

This being said, what are the issues:
1. The doctor is jeopardizing their licensure potentially
2. If it is fraud, there are serious circumstances and this could be severe fines, loss of license, jail time or a combination of the three. The penalties for fraud financially are severe and hence not a good route. Even if an insurance carrier audit was not found fraudulent, there would be a necessary return of funds and this could cash strap the MD
3. What to do in your position:
i. Provide information to the MD to show the incorrect use of coding (I am assuming there is no compliance officer). If it is more than a sole practitioner there are other options but be careful as it could also mean your job; go to the other physicians and one MD being non compliant could draw the whole group into the audit and the other physicians could become partly responsible.
ii. If working with the MD/MDs does not work then the option is to live with it or resign. If it were me, I would document every discussion and keep a copy of the notes at home, including a copy of the 1500 and the chart note (this is to protect you in the future). Document any and every discussion with anyone that has a management position. Even if/when you resign, keep the notes for your protection as this shows you were working to resolve the issue.
iii. Last option - call Medicare and become a whistleblower. I am cautious about this one as it could have a negative impact on your future. If this instance became public knowledge to other MDs, you might have a problem securing a job down the road. If you are going to do this, make sure you have documentation of many cases and then find another job and then become a whistleblower.

I personally am in favor of training and working with the MD. Let them know of the horror stories out there and that they could end up in a similar situation. There are many examples on the OIG/Medicare website or CCA's.

Resign and move on would be the final stage as you do not want to be involved in a practice that is not reputable.

FTessaBartels · #6 01-11-2012, 09:25 AM

Michael Doyle wrote (in part): I would document every discussion and keep a copy of the notes at home, including a copy of the 1500 and the chart note (this is to protect you in the future). Document any and every discussion with anyone that has a management position. Even if/when you resign, keep the notes for your protection as this shows you were working to resolve the issue.

You may be in serious violation of HIPAA rules/regulations by taking patients private medical records home with you. If you are going to keep copies at home make very sure they are completely scrubbed ... NO identifying information. Of course, that means they will be less valuable as "proof." Catch 22 ...

Hope that helps.

F Tessa Bartels, CPC, CEMC