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beachbabi

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My company wants me to take on a new responsibility of entering office charges. These office charges are not upfront coded. The nurse marks the ticket. 85% of these tickets are submitted when dictation is not even ready. I am the only Certified Coder in the office of 19 physicians. I do casually perform E/M audits. I do not feel comfortable or ethically correct in submitting these office charges my company is wanting without reviewing documentation on each patient to verify I am appending the correct CPT code. I feel as a CPC, I should not be filing any charges to an insurance company that are not correct. Am I wrong to express my concern to my employer?
 
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My company wants me to take on a new responsibility of entering office charges. These office charges are not upfront coded. The nurse marks the ticket. 85% of these tickets are submitted when dictation is not even ready. I am the only Certified Coder in the office of 19 physicians. I do casually perform E/M audits. I do not feel comfortable or ethically correct in submitting these office charges my company is wanting without reviewing documentation on each patient to verify I am appending the correct CPT code. I feel as a CPC, I should not be filing any charges to an insurance company that are not correct. Am I wrong to express my concern to my employer?

Rule #1 above all else - You should never bill for services until after the provider has signed off on the documentation. I agree 100% that you should review the documentation before billing - you're the certified coder, not the nurses. It's your neck on the line for those codes, you have every right to make sure you're compliant.
 

Pam Brooks

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What are they doing now? Just because you're a certified coder being asked to submit charges for which there is no complete documentation doesn't make it any less risky to the practice--and since you know it's going on, you probably should speak up because they're already in hot water from a compliance perspective. However, here's your chance to help out. I wouldn't approach it from the point of view "I could get into trouble"...I'd suggest that you tell them that you have a better idea of helping out that meets compliance, because everyone wants to always do the right thing from a patient-care and risk perspective. If you go in loaded for bear because you're the almighty "certified coder", you'll get pushback, I promise you. Make this about their success as a practice, not about you.

As you well know, providers/practices should not submit charges without making sure documentation has been reviewed for completion, accuracy and substance, in order to assign the correct CPT and diagnosis. But it does not have to be done by a certified coder. The physician...whose name is on the claim form, actually can be trained to authenticate their own work. Frankly, in the interest of time, with 19 providers, it's going to be nearly impossible for you to review all of the charges entirely prior to charge posting and claim drop. Short of quitting your job, you'll need to devise a solution. Perhaps you can make a plan to audit just a percentage of the E&M visits, (once the note is signed), and do a full review of all procedures. In the old days, coders looked at everything before it went out the door. Now, with electronic health records, and increased volumes, coders find that if they do a good job training their physicians, they can do post-charge reviews with confidence. You may want to ask if there can be a timeline that providers have to follow to get their documentation done: 48-72 hours is the industry standard. There may be charges you won't need to audit; just review that documentation has been done, such as office labs, vaccines, etc. Maybe you can post the charges, but release claims only after an audit has been completed. There can be a number of ways you can help out without compromising your ethics.

Remember, the physician's name is on the claim form, not yours. Don't worry that the claims police is going to hunt you down if your providers and practice managers don't want to cooperate with your recommendations. If you do your own diligence in educating them on the importance of documentation before billing (and keep records about your discussions with them) then you've done what you can to cover your own liability. If they refuse, or if you can't find time to look at everything, you can at least know that you've given them the information, and what they choose to do with it is their call.
 

beachbabi

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Nurses and physicians assign what E/M level they think is appropriate. It wins through our software and if no CCI edits stop it for modifiers, etc then the system will post them. No dictation is reviewed to see if a -25 modifier is appropriate, dictation supports services charged such as Xrays or injections, incident to guidelines, and alot of over coding of E/M. I can educate them all day long but does no good. I definitely can't review every office visit that comes through every day, that would be over 500 patients a day. I just do not feel comfortable sending charges out of the office that are not accurate.
 

Pam Brooks

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Nurses and physicians assign what E/M level they think is appropriate. It wins through our software and if no CCI edits stop it for modifiers, etc then the system will post them. No dictation is reviewed to see if a -25 modifier is appropriate, dictation supports services charged such as Xrays or injections, incident to guidelines, and alot of over coding of E/M. I can educate them all day long but does no good. I definitely can't review every office visit that comes through every day, that would be over 500 patients a day. I just do not feel comfortable sending charges out of the office that are not accurate.


Are you passing up an opportunity here? It's your call, but you've allowed yourself to be intimidated by people who want you to cower in the corner because you are supposed to be afraid of billing a 99213 instead of a 99214.That's not at all the kind of stuff that gets you into trouble. It's deliberate, knowing, fraudulent billing that gets you into trouble, like billing expensive CT scans that didn't happen. The Modifier's not being appended? Well, they're not going to get paid, that's all, so just run a report of denials and tell them how to fix it. We have a very similar system, edits and all. Review the edits---are they correct? If not, ask if you can build better edits? Figure out what YOU need to do so you are able to do what THEY want you to do. Don't have the attitude that if they don't do it your way, you won't do it....have the attitude you will do it, as long as they will at least let you tell them what major risk factors are (like procedures) and then focus on those until you achieve 90%. Help this practice out and show them what you're made of.
 

avon4117

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Are you passing up an opportunity here? It's your call, but you've allowed yourself to be intimidated by people who want you to cower in the corner because you are supposed to be afraid of billing a 99213 instead of a 99214.That's not at all the kind of stuff that gets you into trouble. It's deliberate, knowing, fraudulent billing that gets you into trouble, like billing expensive CT scans that didn't happen. The Modifier's not being appended? Well, they're not going to get paid, that's all, so just run a report of denials and tell them how to fix it. We have a very similar system, edits and all. Review the edits---are they correct? If not, ask if you can build better edits? Figure out what YOU need to do so you are able to do what THEY want you to do. Don't have the attitude that if they don't do it your way, you won't do it....have the attitude you will do it, as long as they will at least let you tell them what major risk factors are (like procedures) and then focus on those until you achieve 90%. Help this practice out and show them what you're made of.

Absolutely EXCELLENT advice ;)
 

ossierand

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Hello

You hit Pam
Excellent advice, I totally agree with pam. Nowadays with our profession, we have to prove ourselves all the time, and the more we can prove to the providers that we are competent, the more we can get their trust, and in turn finally, they might listen to what we are saying.
 

beachbabi

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So, your recommendation when I review the E/M compared to dictation and the level of service is LOWER than the E/M level the physician is demanding to charge - even after he has been advised the qualifications for that level are not met. You would do what? Charge it out anyway, even though a CPC, CPMA (me) has advised him?

I have been given advice - if I have reviewed the dictation and the services do not corresponde; I am to put a disclaimer on these changes that my company has been made aware, I recommended against the upcoding of charges. However; if it continued to happen - to report them to Medicare, OIG, etc as I could loose my license, be fined, etc.
 
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I apologize for the length of this post, but it's worth the time to read. This is all verbatim - not my words.

"CMS examples of fraud:
- Billing for services and/or supplies that you know were not furnished or provided
- Altering claim forms and/or receipts to receive a higher payment amount
- Billing a Medicare patient above the allowed amount for services
- Billing for services at a higher level than provided or necessary
- Misrepresenting the diagnosis to justify payment
- Falsifying documentation"

"CMS examples of abuse:
- Misusing codes on a claim
- Charging excessively for services or supplies
- Billing for services that were not medically necessary
- Failure to maintain adequate medical or financial records
- Improper billing practices
- Billing Medicare patients a higher fee schedule than non-Medicare patients"

"Fraud and abuse carry stiff penalties under 42 USC § 1320a-7a of the United States Code. Civil monetary penalties (CMPs) may be imposed to varying amounts, depending on the type of violation. These penalties range from $10,000 to $50,000 per violation and can include up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, paid, solicited, or received, whether or not a portion of such remuneration was offered, paid, solicited or received for a lawful purpose. On top of all that, exclusion from participation in the federal healthcare programs and state healthcare programs may be imposed, along with criminal penalties of fines, imprisonment, or both."

"The False Claims Act (31 U.S.C. §§ 3729–3733) states that any person is liable under the FCA if he or she:
(A) Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;
(B) Knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim;...
(C) Conspires to commit a violation of subparagraph (A), (B), (D), (E), (F), or (G);..."

" Relative to healthcare services, examples of fraud or misconduct subject to the False Claims Act include:
- Falsifying a medical chart notation
- Submitting claims for services not performed, not requested, or unnecessary
- Submitting claims for expired drugs
- Upcoding and/or unbundling services
- Submitting claims for physician services performed by a non-physician provider (NPP) without regard to Incident-to guidelines..."

"The FCA is violated by submitting a false claim with knowledge that it is false; however, the Act states that a violation may occur even if there no intent to defraud. The FCA defines the terms as follows:
The terms “knowing” and “knowingly”—

(A) mean that a person, with respect to information—
(i) has actual knowledge of the information;
(ii) acts in deliberate ignorance of the truth or falsity of the information; or
(iii) acts in reckless disregard of the truth or falsity of the information; and

(B) require no proof of specific intent to defraud."

"According to United States legal definitions, deliberate ignorance of the truth means intentionally ignoring a fact when one has every reason to believe about its existence. When knowledge of existence of that fact is an essential part of an offense, such knowledge may be established if the person is aware of a high probability of its existence.

Current penalties are $5,500 to $11,000 per claim. The person in violation will also be liable for the costs of the civil action brought to recover any such penalty or damages. The FCA allows for reduced penalties (mitigation) if the person committing the violation self-discloses, and meets other requirements."


That should clear things up.
 

Pam Brooks

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Danskangel13, you appear angry at our suggestions. I'm sorry we disagree, but I too am very experienced in this field, and work for one of the top hospitals in the Boston area, so I'm hoping that counts for something. I'm not going to get into a shoving match, because I am far above that, but I think your advice is short sighted. The original poster indicated that she could not possibly review each and every claim due to time constraints. That's perfectly fine, and is the protocol in many large and reputable organizations who use random audits and claim edits to support medical necessity in claims submission. What she should do is try to determine where the big issues are, and work from there. This is a project that won't be fixed overnight, and your scare tactics are not helpful. You've not cleared anything up--you've made the original poster worried that she can't possibly do her job. If she follows your advice, she's going to either work 150 hours a week to complete it all, or have to quit out of fear. I believe it's much more important to encourage our colleagues on this board than it is to threaten them with fraud charges. Remember, this is a public forum, and your communication reaches a vast number of people.

beachbabi, you're not going to lose your certification because your providers/managers don't want to have you look at every single claim. If you're uncomfortable there, look for another job, but you'll probably find it's pretty similar every where you work--with technology in place, manual auditing of every single claim is something that is no longer considered a good business strategy. You have to be able to make that technology work for you...with edits that catch claims that should be reviewed, and with software that will assist providers with solid documentation. I am well aware of the false claims act...you are not in violation because you've identified the issues, have documented your concerns and are taking steps to assist your practice. Bravo for you--that's what coders do.
 
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There was no intention to sound angry, so I apologize if that's how it came off. I was merely trying to show how serious problems like this can be, particularly regarding the fact that just "knowing" (for lack of a more accurate word) can land you in hot water. It's a BIG deal, even if it seems it might not; if you're told to do billing like this and you comply simply to abide by the directions to "just do it", it can still come back on you. There'd be no leg to stand on if you argue that you knew it was wrong but you did it anyway because you were told to, if that makes sense.

The information in the post is a direct quote from AAPC, so I can't speak to how they worded it. I was trying to make the point that following direction you know is wrong can have significant costs and that ultimately a decision(s) would have to be made such as quitting the job, refusing to blindly bill and explaining the reasons to a manager or compliance person. Personally I'd try discussing it with someone higher up on the "food chain" and the compliance person with the hopes of having it resolved within the company. I love my job and because I'm a state employee at my facility, I'd never want to quit (for obvious reasons). If I got push-back, certainly I'd be left with no choice but reporting the billing practice to the appropriate state and government agencies. If the poster wanted to keep the job, the anti-retaliation rule would allow the job to be maintained, would resolve the questionable billing problems, and basically take care of the problem(s). I would doubt very highly that the poster's company/business would want to escalate it to that point.

I did check into what MAY happen to a person's certification and this is the answer I got from AAPC:
[ME] For example, if a person with a CPC knowingly billed charges without verifying against the medical record (did not independently review the record) or billed charges before the documentation had been completed, finalized, and signed off on. Could this lead to some sort of probation or revocation of their CPC certification?
[AAPC Rep] That would be violating the code of ethics. So yes, it could potentially revoke their certification.
[AAPC Rep] Do you want the e-mail to file a complaint regarding that?
[ME] Is there a link for the code of ethics?
[AAPC Rep] Let me get it for you!
[AAPC Rep] https://www.aapc.com/aboutus/code-of-ethics.aspx

I most definitely agree about not feeling good about what the poster is being asked to do. I also totally agree keeping documentation of the issue. Emails most certainly; but I always document dates, times, and the content of any discussions I have and with whom I have them. That being said, I'd suggest perhaps keeping such a log in a personal notebook or someplace other than on the company's computer (obviously with no patient specific information or otherwise).

Again, I apologize if I came off as negative. I just would hate to see someone stuck in a bad (and unfair) situation.
 

Pam Brooks

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In an article written by respected healthcare attorney Michael Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, he gives his opinion in line with the OP's initial worry...that being told to bill in a certain way puts her at risk.

With respect to coders, billers, and administrative staff, conspiracy liability — which apparently existed here — is very different than direct liability for merely causing the submission of a false claim. When a coder/biller is directed to submit claims/codes under protest, there is likely little chance of liability. Being told to bill something that you believe is incorrect after raising an objection (preferably in writing) is not likely to lead to allegations of criminal conduct, including conspiracy, especially when the coder/biller does not profit from the error. We should all remember that just because the provider does not agree with the coder’s conclusions as to the appropriate code or method of billing, does not necessarily mean that the physician is committing fraud.

The entire article is located here. https://www.aapc.com/blog/29586-physicians-are-ultimately-liable-but-billing-staff-may-pay-too/


Mike points out that there is a difference between conspiring with a physician to commit fraud versus being directed to submit claims erroneously. My point (and I appreciate the good discussion--thank you everyone), is that coders cannot always police and control physicians in practice.
We can provide advice, offer solutions and make recommendations, but it's the physician who is liable. Once we've done our due diligence, we have to decide whether or not the risk is worth the effort. The AAPC code of ethics is important, but as we know, our work situations are not always black and white. I believe that the OP is being ethical by questioning the activities of the office, and is covering her butt by documenting the process, as Mike suggests above, but she is in no way being unethical by choosing to stay with her organization.
 
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