Wiki Compliance/Fraud ??

[tdsmitchell]

Not sure what to I should do; currently I am doing Physician coding and yesterday I was told that when coding a chart to use the E/M code given by the Dr and only spend time coding the Dx's, what is the compliance/fraud issue with this? Anyone's help/direction is greatly appreciated.

Thank you

 

[kevbshields]

If the physician codes the E/M and is accurate in doing so, there is nothing to prevent him/her from that. While (personally) I don't recommend trying to make physicians into coders, some can be quite accurate and savvy with training. It is the burden of the practice to ensure the accuracy of those E/M through periodic audits.

It isn't fraud unless the providers are misrepresenting what they are doing.

 

[jholt12]

I understand completely your concerns like Kevin stated above there are Dr.'s that do code accurately. What I try to do when I feel like that is get it in writing that is what they want you to do. Like Kevin said it is the burden of the practice. But it makes me personal feel better when I have written documentation on what is being done. Just to cover all your bases.

Julia Holt CPC

 

[tdsmitchell]

thank you, where I was concerned is that we have seen most of the Dr's use a level 3 and most of those should be level 2.

 

[tdsmitchell]

exactly what we are asking for - "in writing please".

 

[Deanne N]

yikes

I believe what your are saying is that this physician is NOT coding acurately-- he is upcoding. Have you told them that you believe he is upcoding and shown them? When you told them this, they responded by telling you to ignore it? Then this is a serious fraud problem, since they have been informed that they are billing incorrectly and are chosing to continue. It is no longer an error-- they are chosing to bill fraudulently.
I agree with these previous folks. Get what they said in writing and document what you told them. If you have been told that your job is diagnosis only, not CPT, ask for that in your job description.
Ironically, your physician is probably doing the work for the higher code; he probably just isn't documenting enough of what he is doing. I'm sure he asks the patient how they are and doing the same exam he's done for 20 years on autopilot, and he's just not writing it all down if it is normal.
Unfortunately most coders need their jobs and fear losing them, for good reason. It is easier getting rid of you than arguing with the physician. If you have a compliance officer, this is their job and you should talk to them about how the documentation needs to improve. If you don't have one, or if you are it, can you set up a teaching meeting with the physician? You can say it is about 2009 updates and changes. Talk about the changes in 2009 ICD-9s and how some of them are more specific and require more documentation (for instance, the new fever codes) and then transition into what you see that is missing in the E/M documentation.

 

[kevbshields]

With this new information you've provided, I'd also like to recommend remedy if strega's suggestions do not work out. Call a lawyer if the efforts you make are moot. This attorney should be someone who could possibly have to represent you when/if any incidents occurred. If you are fired, you'd have proof that you contacted an attorney in addition to addressing the problem internally; if an investigation surrounding the practice erupts, you also had contacted an attorney. Those folks are experts at supplying legal advice--most of us here on the forum are not.

After attending an Ingenix national conference session on this a few years ago, it became clear that to protect yourself, you must have a plan B--which involves a lawyer who understands your situation and can provide thorough guidance. I wish you the best, but plan for a worse case scenario if your efforts elicit no action on the practice's part. Although you are currently charged with protecting your provider's interests, you must also be aware of your own.

I wish you the best of luck in finding a solution early on.