Wiki Releasing charges without first reviewing the note to support the E&M level chosen?

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aimes

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I have a couple questions and would like the opinion of other coders/clinics.
How many practices are releasing charges without first reviewing the note to make sure the E&M level chosen by the provider matches the documentation?
How many coders are letting the Dr's choose the level of E&M and just releasing these claims "as is" without review?
and
If the work flow is done like this, what kinds of liability is it to the coder if there have been previous audits done, where level 99215 was chosen by the provider frequently, but the note only supports a 99213. If the coders know this from previous audits, and are now being asked to change workflow to just "release" charges without coding the levels and audit after the fact, what are the liabilities to the coder?
Also, if there is a "new trend" in coder workflow like stated above, is there a compliance plan in place to do audits after the non reviewed/coded release of claims?
Back story...As a coder, I believe notes should be reviewed, and coded correctly PRIOR to the release of claims as the documentation must match the level of service billed. However, I am being told that this is no longer the common practice and that charges should be released with the E&M level the Dr chooses and that audits can be performed after and education on the wrong ones later and that this falls back on the Dr. I do not agree with this and am looking for advice from other coders and getting your thoughts on this debate.
 
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I review every single E&M level prior to the claims being billed.

That being said, I code a specialty that doesn't use a high volume of E&M codes. Even though my 2 physicians treat a lot of patients, they might have 25 billable E&M visits a week...combined.

(I code Radiation Oncology. New patients have an initial consultation No E&M during active treatment and for 90 days after. (E&M is bundled into the treatment management CPT). After 90 days, the patient typically has at least one follow-up E&M. There's not a high volume of billable E&M services in that specialty.)

I can't speak for what's typical in primary care or other specialties that are more E&M driven. Hope you get some useful input here.
 
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aimes said:
I have a couple questions and would like the opinion of other coders/clinics.
How many practices are releasing charges without first reviewing the note to make sure the E&M level chosen by the provider matches the documentation?
How many coders are letting the Dr's choose the level of E&M and just releasing these claims "as is" without review?
and
If the work flow is done like this, what kinds of liability is it to the coder if there have been previous audits done, where level 99215 was chosen by the provider frequently, but the note only supports a 99213. If the coders know this from previous audits, and are now being asked to change workflow to just "release" charges without coding the levels and audit after the fact, what are the liabilities to the coder?
Also, if there is a "new trend" in coder workflow like stated above, is there a compliance plan in place to do audits after the non reviewed/coded release of claims?
Back story...As a coder, I believe notes should be reviewed, and coded correctly PRIOR to the release of claims as the documentation must match the level of service billed. However, I am being told that this is no longer the common practice and that charges should be released with the E&M level the Dr chooses and that audits can be performed after and education on the wrong ones later and that this falls back on the Dr. I do not agree with this and am looking for advice from other coders and getting your thoughts on this debate.
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While doctors do have culpability, they can legally plead ignorance since they are not coders are don't keep up with the coding changes. Certified coders cannot plead ignorance as we are expected to keep up with coding changes. I have never understood why companies think it's OK for a non-coder to choose codes. From my experience most of the codes are reviewed by a coder before submitting to insurance. I think all codes should be reviewed by a certified coder. A dose of reality. If your company follows this work-flow model they are asking for problems. Are you sending corrected claims when you identify an incorrect code through your audit? You should be. If your doctor wants to bill 99215's that are not supported by documentation that is asking for trouble too. Insurance companies can run reports and see if your doctor's codes are in line with what their peers are billing. If your billing unsupported 99215 codes your doctor will stick out and get someone's attention. If your company forces you to bill out codes that you are not supported, keep track. I had to do it for a while and there was a place in the EMR where I could write an internal note. I used that. Most coders that I interact with all code charges before billing.
 
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The reality is, in many practices, there is not enough manpower to manually code every single visit. In many revenue cycles the claims go out through a scrubber and there is selective or exception editing. This is why there are internal claim scrubbers and edits internally in PM/EHR software. The claims also hit edits in the clearinghouse before going to the payer. For example, some programs are set up to stop every E/M that is a level 5 for a coder to review yet might allow level 3s to go out unless they hit some other edit such as a modifier 25, etc. Others may be set up to stop anything with a 59 on it. Some may not allow a consult code due to restrictions, etc. I have seen where operative cases are only allowed to be manually coded by a certified coder but providers are choosing their own E/Ms. It depends on the provider too, many I have worked with understand coding and take an active role while others do not.
At the end of the day the provider billing is responsible for their charges.
I am not saying one way is right or wrong. Technically, nothing should be billed without a signature, the complete final note, and being checked by a coder, but that's just not how it works these days.
I think there could be more to the story, is this a new employer for you, a new process, new EHR, new management? What exactly is being asked of the coder in this situation? If you have to actually "touch" the claim and manually release it, can you decline unless you are able to review the documentation? Is there an automatic system where you are only seeing the "rejected" or edited claims?
It really depends on the practice, specialty, type of services, size, etc. Ask a hospital coder working in Epic for a huge health system, no way they touch every claim.
 
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Regarding coder liability, I am not a lawyer but the billing practitioner is ultimately responsible for the accuracy of the claims that are submitted in their name. If you look at the back of the CMS-1500 form you'll see an attestation by the billing provider that the information is accurate and the services on the claim are medically necessary. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1500.pdf

I've covered health care compliance for a long time and it is very rare for coders to be penalized for improper coding or fraud. Typically it happens when investigators believe the coder was involved in coming up with a scheme that resulted in improper coding or fraud and/or benefited directly from the fraud.

Here's one case https://www.justice.gov/opa/pr/medical-biller-sentenced-45-months-prison-role-4-million-health-care-fraud-scheme

On the other hand, providers have been penalized more heavily if investigators learn that internal staff or external consultants had warned the provider that their billing was non-compliant.

My question is this: What's the process for returning overpayments if you find any during the audit?
 
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My two cents echos the above opinions.
As mentioned above, a lot of whether or not a coder is involved in the pre-submission process is up to the employer. In my organization, almost all clinicians are responsible for coding all their own services and are not reviewed by a coder prior to submission. The coding teams in my organization are mainly for audit, education, scrubbing, and denials. There are some coders doing actual coding (reading records and assigning CPT/ICD10/mods) but not many. My personal opinion is that many providers are not the best person qualified to do that work, as they simply do not receive the training and education that coders do.
However, it terms of "liability", the clinician has the ultimate responsibility.
 
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I agree, good advice in all of these posts here. I've seen this done in different ways by different practices, from both ends of the spectrum - from having coders assigning or validating every code, to providers doing it all. It's ultimately the organization's owners and managers who are responsible for ensuring accurate coding, and they can go about that in different ways. Personally, I don't think it's a good use of costly healthcare resources to have a coder review every record. What makes sense to me is to have an audit plan that identifies where the potential problems lie and to use coders to handle those types of cases and to target those areas for improvement. While it's true that many providers are not good coders, that doesn't mean that they are not able to do any coding at all, nor does it mean that the types of errors they make are necessarily the kinds of errors that would put the practice at risk. (And it's worth remembering that we coders make our own errors as well.) And in fact, there are in fact some providers who are quite good at coding. If an organization can identify those providers and allow them to choose their own codes, it doesn't serve any purposes to require a coder to go back through that provider's work, except perhaps as a periodic check to ensure that quality is being maintained. In my experience, the best practice is to gather an understanding of the organization's strengths and weaknesses and risk areas in coding, and to use coders to strategically address or correct the problems in those particular areas.
 
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amyjph said:
The reality is, in many practices, there is not enough manpower to manually code every single visit. In many revenue cycles the claims go out through a scrubber and there is selective or exception editing. This is why there are internal claim scrubbers and edits internally in PM/EHR software. The claims also hit edits in the clearinghouse before going to the payer. For example, some programs are set up to stop every E/M that is a level 5 for a coder to review yet might allow level 3s to go out unless they hit some other edit such as a modifier 25, etc. Others may be set up to stop anything with a 59 on it. Some may not allow a consult code due to restrictions, etc. I have seen where operative cases are only allowed to be manually coded by a certified coder but providers are choosing their own E/Ms. It depends on the provider too, many I have worked with understand coding and take an active role while others do not.
At the end of the day the provider billing is responsible for their charges.
I am not saying one way is right or wrong. Technically, nothing should be billed without a signature, the complete final note, and being checked by a coder, but that's just not how it works these days.
I think there could be more to the story, is this a new employer for you, a new process, new EHR, new management? What exactly is being asked of the coder in this situation? If you have to actually "touch" the claim and manually release it, can you decline unless you are able to review the documentation? Is there an automatic system where you are only seeing the "rejected" or edited claims?
It really depends on the practice, specialty, type of services, size, etc. Ask a hospital coder working in Epic for a huge health system, no way they touch every claim.
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Currently we touch every single charge and make sure the code billed matches the providers documentation. They are wanting to implement a New process where we only go in to each charge and correct diagnosis and leave whatever E&M the providers have chosen in place. There are quite a few instances where 99215's are billed but documentation only supports a 99213 or 99214.
 
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jkyles said:
Regarding coder liability, I am not a lawyer but the billing practitioner is ultimately responsible for the accuracy of the claims that are submitted in their name. If you look at the back of the CMS-1500 form you'll see an attestation by the billing provider that the information is accurate and the services on the claim are medically necessary. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1500.pdf

I've covered health care compliance for a long time and it is very rare for coders to be penalized for improper coding or fraud. Typically it happens when investigators believe the coder was involved in coming up with a scheme that resulted in improper coding or fraud and/or benefited directly from the fraud.

Here's one case https://www.justice.gov/opa/pr/medical-biller-sentenced-45-months-prison-role-4-million-health-care-fraud-scheme

On the other hand, providers have been penalized more heavily if investigators learn that internal staff or external consultants had warned the provider that their billing was non-compliant.

My question is this: What's the process for returning overpayments if you find any during the audit?
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We do internal audits and educate the providers on proper documentation and what needs to be corrected or done differently in order to bill the levels that they have chosen.
 
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My final (?) thoughts on this (which are based on years of working with people who've been doing this for decades):
1. Providers need to see the money: How much money they left behind when they undercode; how much money they have to return when they upcode.
2. Practices must have a process for returning overpayments. For example, Medicare gives practices 60 days to return overpayments after a reasonable period to investigate the problem. That process should be taught to everyone involved in the revenue cycle, including the treating practitioners. It helps them understand that upcoding creates a big hassle that wastes time and money.
 
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smithca said:
Has anyone asked a legal representative what outcomes could happen to a coder in this situation?
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If your employer has instructed you that your responsibility is to correct the diagnosis code only, I don't see how a coder could have any legal repercussions by simply performing their required job tasks. Generally, legal outcomes for coders are rare and come into play for things like fraud. That is not the situation here.
 
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csperoni said:
If your employer has instructed you that your responsibility is to correct the diagnosis code only, I don't see how a coder could have any legal repercussions by simply performing their required job tasks. Generally, legal outcomes for coders are rare and come into play for things like fraud. That is not the situation here.
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So to go a little more in depth...
As stated our coders have always reviewed documentation and coded correctly prior to submission, in order to submit accurate and clean claims. Our Financial dept/CFO pulled reports to show E&M levels by provider, as well as revenue lost due to coders changing codes that providers are putting on charges. Historically our providers tend to submit a higher level than what their documentation supports, and sometimes but not often lower levels. We have gathered this information and done numerous and continuous education with them. It was then determined by finance and presented to us, that since revenue is being lost and due to lack of man power, a new financial initiative should be put into place, (again, documentation does not support the levels providers often are choosing).
Here is the new plan... Due to lost revenue and lack of man power (volume of charges) it was determined that the coders will 1. Leave the E&M levels at whatever the Dr/provider chooses 2. Continue to review all charges to apply only the correct ICD codes 3. Perform POST submission audits.
Our concern is, we feel this may be a violation of the False claims act as we will be knowingly submitting charges that we Know can and are many times incorrect due to the current work flow, audit and education history. Also, there is currently no recoup/refund policy in place for post audits of submitted charges, only educating the providers. Currently when we do audits it is Prior to submitting charges, so those charges are audited, coded and submitted clean and then the data is gathered and presented to the providers and managers for review.
The argument we are given, and I agree to a point, is that other clinics release charges without being reviewed. While yes, other clinics release charges, many are electronically batch released, and there are holds and edits in place to capture errors by the scrubber. The coders are not still going into every charge, and potentially releasing charges they know are incorrect.
This is our whole delima. We don't want to violate the False Claims act or do anything unethical.
 
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aimes said:
So to go a little more in depth...
As stated our coders have always reviewed documentation and coded correctly prior to submission, in order to submit accurate and clean claims. Our Financial dept/CFO pulled reports to show E&M levels by provider, as well as revenue lost due to coders changing codes that providers are putting on charges. Historically our providers tend to submit a higher level than what their documentation supports, and sometimes but not often lower levels. We have gathered this information and done numerous and continuous education with them. It was then determined by finance and presented to us, that since revenue is being lost and due to lack of man power, a new financial initiative should be put into place, (again, documentation does not support the levels providers often are choosing).
Here is the new plan... Due to lost revenue and lack of man power (volume of charges) it was determined that the coders will 1. Leave the E&M levels at whatever the Dr/provider chooses 2. Continue to review all charges to apply only the correct ICD codes 3. Perform POST submission audits.
Our concern is, we feel this may be a violation of the False claims act as we will be knowingly submitting charges that we Know can and are many times incorrect due to the current work flow, audit and education history. Also, there is currently no recoup/refund policy in place for post audits of submitted charges, only educating the providers. Currently when we do audits it is Prior to submitting charges, so those charges are audited, coded and submitted clean and then the data is gathered and presented to the providers and managers for review.
The argument we are given, and I agree to a point, is that other clinics release charges without being reviewed. While yes, other clinics release charges, many are electronically batch released, and there are holds and edits in place to capture errors by the scrubber. The coders are not still going into every charge, and potentially releasing charges they know are incorrect.
This is our whole delima. We don't want to violate the False Claims act or do anything unethical.
Click to expand...


One key point here to me is that your finance department said "since revenue is being lost..."

Real revenue would not be lost by billing the E/M level correctly. They are choosing to ignore this to bring in more money than they are actually due. This isn't an error or lack of education - it is intentional at this point.

The intent is supported by the fact that they have no process for returning overpayments once detected on a post payment audit.

I would not want to be a part of that. I'd look for a new job, and also report it.
 
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sls314 said:
One key point here to me is that your finance department said "since revenue is being lost..."

Real revenue would not be lost by billing the E/M level correctly. They are choosing to ignore this to bring in more money than they are actually due. This isn't an error or lack of education - it is intentional at this point.

The intent is supported by the fact that they have no process for returning overpayments once detected on a post payment audit.

I would not want to be a part of that. I'd look for a new job, and also report it.
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Amen !
 
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First of all - I still think it is highly unlikely that coding staff would be held liable in this situation. Especially since you've shared your concerns with the practice ownership. But if there were to be an investigation anyone who is questioned by the investigators will need to have an attorney through the process.

Second - the lack of process for returning the overpayments is a very large red flag. There's no way for an organization to convincingly say "We conduct audits, we identify overpayments during audit, but we don't return the overpayments." Again, if you're billing Medicare or in a state that has a law that is similar to the 60-day overpayment rule, they're really in a bad position.

However, I wonder if they would be open to having a consult with a health care attorney. The attorney will tell them the same thing, but it might stick because it is someone outside the group.
 
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Does your group or practice have an internal compliance hotline? Do they have a mechanism and process for staff concerns?
Are you a staff coder reporting to supervisors, managers, etc. but not a decision maker and no responsibility for supervising others?
I think a step back needs to be taken and follow the proper channels in your organization for this type concern. There could be a lot of different factors at play and this is turning into a bigger more legal discussion than is really suited for a coding forum. If you are that concerned you should go to your leadership and/or internal compliance policy/process. The financial department and/or CFO, CCO, CEO or any manager or supervisor should take these concerns. I understand the concerns and have had them in past experiences however, going to company policy was best practice as a first step.
 
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