General Surgery Coding Alert

Question: I hear that small practices need to implement a coding compliance plan. How does our practice begin? Can we obtain a working model to customize for our own use?

Georgia Subscriber

Answer: A compliance plan should outline steps for the proper reporting of errors and the appropriate corrective actions. Arlene Morrow, CPC, an independent general surgery coding and reimbursement specialist in Tampa, Fla., notes that although the Office of Inspector General (OIG) model is currently voluntary, many coding specialists expect it to become mandatory soon.

When establishing an internal auditing system make sure the chart reviews are done prospectively (i.e., before the claims are sent to the carrier for payment), Morrow says. She cites legal opinions that state retrospective audits may leave a practice in a precarious position if an error is discovered and not reported particularly if there is no compliance plan in place.

Anything filed on a HCFA 1500 claim form, whether on paper or electronically, to Medicare, Medicaid or a private payer, is subject to HIPAA [the Health Insurance Portability and Accessibility Act of 1996], Morrow explains. A retrospective audit is just too risky because if the coder saw the claim or charge ticket and knew that there was fraudulent activity, he or she might be considered a witness to a felony.

An initial compliance analysis should begin with what Morrow calls a baseline fraud audit. This involves a review of procedure analysis reports that contrast individual physician billing patterns with those of the whole practice as a way to identify aberrant patterns. Sometimes one physician in a group is billing only level-two E/Ms, while another doctor is billing only level fives. The report allows the practice to identify those kind of patterns, she says.

Morrow also recommends practices check specific codes regularly used by surgeons that are known to be under special scrutiny. We know that 99291 (critical care), 99214 (level-four established patient visit) and 99233 (level-three inpatient visit) are highly targeted for review. I want to see a good curve on those [codes] to illustrate they arent being overutilized, she explains. The same applies to in-house vascular studies and to any kind of foot or wound care, such as debridements, which tend to be highly scrutinized.

When performing the audits, Morrow wants to see clear documentation of medical necessity and, for surgical procedures, an absence of unbundling. For example, the surgeon excises a benign legion (11400) and performs a simple closure of the wound caused by the excision (12001). The latter procedure is bundled with the excision and should not be billed separately.

For E/M claims, Morrow will record both the code charged and the supporting documentation and note what was missing to educate the surgeons on how to code more appropriately. Therefore, the audit also serves as an educational tool.

Morrow notes that several model compliance plans are available. For example, in September 2000, the OIG posted on its Web site the final version of a voluntary compliance program for individual and small group physician practices. In it, the OIG identifies the following risk areas associated with coding and billing:

Billing for items or services not rendered or not provided as claimed;
Submitting claims for equipment, medical supplies and services that are not reasonable and necessary;
Double billing;
Billing for noncovered services as if covered;
Knowing misuse of provider identification numbers, which results in improper billing;
Billing for unbundled services;
Failure to use coding modifiers properly; and
Upcoding the level of service provided.

The compliance plan can be downloaded free by visiting www.hhs.gov/oig, choosing the compliance guidance link and selecting Final Compliance Program for Individual and Small Group Physician Practices. Although an extensive and, in some ways, difficult document, Morrow warns that simply purchasing a four-page compliance template from an Internet vendor is not enough to guarantee an effective program for coding compliance.