Documentation and Coding Accuracy Concern

By Michael Miscoe, Esq.

Here is an interesting story.  What is most notable is that the estimated total of “improper payments” is based on alleged coding and documentation deficiencies.  For the coding errors, is it that the code did not represent the service actually performed or that a documentation deficiency was found that permitted a change to the code.  What seems to be missing is the question of whether the patients involved were entitled to receive the service paid for – i.e. did Medicare actually get what it paid for?  When you omit from the analysis whether there was a real patient with a real problem that got a real service with a real benefit from the analysis, it is easy to identify significant overpayment figures.  Regardless, this demonstrates the continuing focus on the documentation as the basis for payment as opposed to whether a service really happened or not. This is an unfortunate misinterpretation of Section 1833(e) of the SSA but one that prevails in post payment analysis.  Providers should take heed.

Report Reveals Medicare Made $6.7 Billion In Improper Payments In 2010.

USA Today (5/29, Kennedy) reports that HHS’ Inspector General is set to release a report Thursday revealing that Medicare “paid out $6.7 billion in 2010 for health care visits that were improperly coded or lacked documentation.” In total, that represents “21% of Medicare’s total budget for diagnostic and assessment visits.” Sen. Bill Nelson (D-FL), who chairs the Senate Special Committee on Aging, said, “We have to do a better job of curbing improper payments and protecting taxpayer dollars,” before “adding that he looks forward to working with the new HHS secretary to fix the problem.” Should she be confirmed, nominee Sylvia Mathews Burwell “said she would work toward making sure errors and fraud are caught before payments are made to providers.” ProPublica (5/29, Ornstein) also reports on the inspector general’s report.


Michael Miscoe
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Mr. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA has over 20 years of experience in healthcare coding and over sixteen years as a compliance expert, forensic coding expert and consultant. He has provided expert analysis and testimony on a wide range of coding and compliance issues in civil and criminal cases and his law practice concentrates exclusively on representation of healthcare providers in post-payment audits as well as with responding to HIPAA OCR issues. He has an extensive national speaking background and has been published in numerous national publications on a variety of coding, compliance and health law topics.

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