Take a Refresher on Coder Liability
What you don’t know can hurt you.
by Barbara Cataletto, MBA, CPC
In addition to acquiring all the necessary tools and education needed to code and bill, you also are responsible to adhere to regulations governing reimbursement. Failure to perform these duties may result in a direct violation of contractual and professional obligation.
Understand Areas of Risk
Key areas of coding violations, according to the federal government and national coding certification programs, are:
Participating in, agreeing to, or hiding improper coding, knowing that it’s improper coding
If you purposefully involve yourself in supporting fraud, your liability can be enormous. If you feel fraud is committed, document the process that you believe is a violation and present this to your superiors or clients to promote dialogue and correction. If you do not get results that protect you, look for a new position somewhere else.
Billing for items or services not actually documented
Before you push the fraud component here, communicate with the healthcare provider to make sure you are certain the items are properly documented as required. Educate the provider about the documentation requirements needed to support the billing.
This occurs when a billing entity uses separate billing codes for services with an aggregate billing code. This area of coding requires a great deal of scrutiny because payers use several resources (e.g., National Correct Coding Initiative edits, CPT® guidelines, etc.). The practice or facility must abide by regulated industry standards throughout the billing process.
Upcoding is billing a code that provides a higher reimbursement rate than the code that accurately reflects the level of service performed on the patient. The greatest revenue is generated with the highest-level coding possible, but don’t be persuaded to push the limit by upcoding. If you can’t appeal it, you shouldn’t code it.
Inappropriate balance billing
This is billing Medicare beneficiaries for the difference between the provider’s fee and the Medicare Part B allowable payment.
If you are contracted with carriers, most patient balances for contractual agreement are identified on the explanation of benefits. In most cases, it is inappropriate to bill patients for items not covered or approved. Be cautious of billing for patient balances that you think should have been covered, but weren’t approved, or were bundled into other procedures. Perform the appropriate appeal for charges you believe were denied unjustly.
Inadequate resolution of overpayments
This means accepting improper or excessive payment as a result of patient billing or claims processing errors. Never ignore an overpayment or refund request, but do not refund blindly. Always respond in writing and ask the carrier to provide an acceptable explanation as to why a refund is justified. Be prepared to appeal if you believe the request is unjustified.
Know Your Potential Criminal Exposure
Remember that you have made a commitment to be ethical and moral, to follow industry guidelines and standards, and to continue your education. As a professional, you know the importance of being fully informed of any changes in the ever-evolving coding world. Education is readily available through AAPC and a variety of specialty education providers.
Although honest mistakes and omissions can occur in every business, it’s important for the integrity of the coding profession and the healthcare industry to remain mindful of all acceptable coding and billing practices. Compliance programs and continued education will help you reduce unintended violations and provide an outlet to report violations, if they occur.
Even if you received no compensation, did not actually perform the improper coding, and fear for the loss of employment, you should expose criminal behaviors. You can do this by reporting anonymously to the insurance boards of your state, directly to the carrier, etc. Failure to report such crimes may result in accessory charges by officials. Be sure to protect yourself and the patients involved by being proactive and responsible.
In the end, you are ultimately responsible for yourself. As Shakespeare said in act 1, scene 3 of Hamlet:
“This above all—to thine own self be true,
And it must follow, as the night the day,
Thou canst not then be false to any man.”
These were wise words then and they are wise words now.
Barbara Cataletto, MBA, CPC, is CEO and founder of Business Dynamics, Inc. She is considered an expert in spine coding and reimbursement, and sits on the International Society for the Advancement of Spine Surgery Coding Task Force and Adelphi University’s Robert B. Willumstad School of Business board of advisors, has received a National Stevie Award, and was most recently named one of the 50 Most Influential Women in Business on Long Island, N.Y. Cataletto is a member of AAPC’s Jamaica, N.Y., local chapter. For more information about Business Dynamics RCM, an affiliate of Business Dynamics, Inc., please visit their website at www.businessdynamicsrcm.com. For more information about The Business of Spine, visit their website at www.thebusinessofspine.com.