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jwestfall

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Can anyone tell me where I can find documentation that a provider can be fined for under coding? My organization has hired a consulting firm to train on E/M auditing and have said repeatedly that providers can be fined for this, but have not as of yet been able to produce any documentation. I have a very disgruntled physician that wants proof of this!
 
Maybe she is talking about the "False Claims Act"??? Google it...you'll see they can get in trouble for submitting "false claims". Undercoding is just as wrong as overcoding when done on purpose. (i.e. undercoding to give cash pt's a break=not fair to others)
 
True, you could theoretically be fined under the False Claims Act but probably not likely. A more likely scenario is being ecluded under CMS. Repeated undercoding could cause your practice to appear as an outlier and trigger an audit. Intentional undercoding could result in exclusion and possibly in fines.
 
I tell my students to think of it like this. To code anything other than what is documented could be viewed as fraudulent coding.
 
What if you get a waiver of responsibility from the provider? Does that exclude you from countability? Does anyone know?
 
It does not exclude you if you are assigning the code to the claim. I worked with a billing service that thought that but their contract told the providers that coders would go over all codes assigned by the physician before putting them on claims. To make a long story short, when things got busy she did not do this she just had clerks data entry the codes to the claims. When she did check with an attorney at my insistence she found out that each person doing the data entry was responsible for the validity of those codes. So If your job is a coder then you are responsible to validate the codes assigned by the provider. If your job is a data entry clerk then be certain that your job description is clear on that.
 
under coding

I have been told for years that it's fraudulent, but even the Medisync MD doing the training can't give me an example of a provider being fined or show me in writing that they can be fined.
 
I totally understand that aspect. I am not a clerk, I am a Coding Educator with 18 years of experience. I am simply arguing with a provider that is consistently under coding his established patients and he feels he is justified if he so choosed to assign a code level that is below what the documentation warrants. He is demanding that I show him in writing that a provider can be fined for under coding!
 
Well you might check the OIG website, But also this is an example of a false claim where the false claims statute would apply to falsly represent the service in his documentation as one thing but to the patient as another, also what about discrimination to discriminate to some but not to all. It is intentional misrepresentation on his part and I think that is the direction to go rather than undercodeing, which is the same as overcodeingand that is that both misrepresent the service rendered.
It would be the same as charging for an xray when you do an open heart bypass or an exploratory lap when you do a hysterectomy.
 
Yep! Intentionally undercoding is cetainly a violation of the False Claims Act. I honestly don't know if anyone has been prosecuted for undercoding but would not take the chance. IMHO, it is unethical, even if it wasn't illegal.
 
Administrator

Under coding and over coding is fraud. How about recoding? How many times can you recode a claim? Some doctors call this practice recoding and they recode (under code) the claims if Medicare denied or if the claim was never worked and is past the timely filling. The doctor then recode the claim and submit the claim as a brand new claim. Is this Legal? It is my opinion that is the same as under coding or over coding and is fraud. What is your opinion? Maria
 
My opinion is that knowingly submitting a claim that is coded incorrectly is fraud. "Coding to get paid" is always wrong (with the exception of those payers who give you specific instructions). I thinks it's okay to recode if the claim was coded incorrectly the first time. I also think it's okay to recode as many times as it takes until it's coded correctly. However, if you do this routinely, i would expect auditors to come knocking. At the very least I would expect one of those infamous "re-education" letters from my Medicare carrier. i'm not sure how recoding and billing as a new claim would ever get you past timely-filing requirements but if a claim has been recoded, I think you should follow the payer's corrected claim guidelines.
 
undercoding

Let me correct my statement that undercoding and overcoding is fraud. It is only fraud if done on purpose. You can undercode or overcode in error and that is not fraud. you can correct the claim and re-file. I never heard of a physician penalized for undercoding only for overcoding. If the documentation sopports the level of care, you can submit a corrected claim as long is supported by documentation. The False Claims Act imposes liability on any person who submits a claim to the federal government that he or whe knows (or shold know) is false. You can make your own definition of false claim.
 
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