Radiology Coding Alert

A central focus of Medicares audit campaign in the upcoming year will be compliance within solo and small group practices, according to Kimberly Brandt, senior counsel with the Office of the Inspector Generals (OIG) Civil Recoveries Branch. She says OIG is drafting a model compliance plan that will emphasize 12 areas that have been identified as particularly problematic with small practice groupsa category that aptly describes the majority of radiology practices:

1. Kickbacks
2. Routine waiver of co-payments and deductibles
3. Billing for services not rendered
4. Upcoding
5. Unbundling
6. Double-billing
7. Billing for physician services rendered by
nonphysicians
8. Medical necessity
9. Misrepresenting diagnosis to justify services
10. Completing certificates of medical necessity for patients not personally or professionally known by the physician
11. Billing Medicare or Medicaid for investigational
research, medications, and/or procedures without proper authorizations
12. Billing for a noncovered service as if covered

Compliance Plan Saves Moneyand Headaches

The most effective response to Medicares focus on small practices is to develop and follow an internal compliance plan, advises Thomas A. Kent, CMM, president of Kent Medical Management in Baltimore, Md., who has worked with national medical centers on compliance.

Its not difficult, but it can save any radiology group a lot of headaches, he points out. A compliance plan can be as simple as a short booklet that describes the billing process in your office. Components that should be addressed and clearly outlined, Kent says, include:

Which individuals handle the billing process;

What responsibility each assumes in the process;

Who reviews claims that have been denied by Medicare;

What system is in place to track denials and identify any patterns that indicate errors;

How denial patterns, errors or problems are communicated to office and medical staff; and

What system is in place to correct problems and ensure the situation has been resolved.

It is my firm belief that most radiologistsand the majority of other physiciansare very honest, Kent says. Many of the compliance problems arent conscious attempts to defraud the government. They result when someone is documenting or reporting a service incorrectly and isnt aware of it. Unfortunately when it comes to fraud, the government does not have to prove intent. They only have to show a pattern of noncompliance.

A well-thought-out compliance plan, he adds, indicates that a radiology practice has made a good-faith effort to comply with national Medicare and local carrier requirements. If you have a plan in place and can demonstrate that you abide by it, it will help you minimize any penalties in case Medicare conducts an audit and finds problems.

Another effective strategy, Kent says, is to emphasize educational programs that keep medical and office staff abreast of coding and compliance issues. Obviously, everyone [...]