Wiki What are the legal and reimbursement repercussions of incorrect dx codes?

Create Wiki Sort by date
L

LauraNewYork

Networker
Messages
68
Location
Clay, NY
Best answers
0
Our practice has recently changed the method that claims are sent out. Currently the providers chose the level and the dx codes 😟. Biannual auditing of the providers was put in place. Coders are not allowed to make changes to the submitted level or submitted dx codes. Coders add modifiers as needed. The coders have strenuously objected to the change, knowing that it would cause a lot of back end work.

As expected, we have seen a huge number of denials related to dx code errors. I just discovered that our EMR does not allow the providers to put the dx codes in a specified order, rather the codes are randomly applied to the charge. I have completed multiple searches regarding the legal repercussions of incorrect dx coding, but am having difficulty teasing out legal repercussions of incorrect dx coding as a separate issue from level or modifier coding. EXAMPLE: a charge went out with gastroenteritis as the primary code when the patient was actually seen for breast cancer. The breast cancer was the 5th listed code. Another charge went out with multiple R codes when they were seen for a cancer evaluation which wasn't even listed on the charge.

I would greatly appreciate any input regarding the legal repercussions of incorrect dx coding when billing level and modifier coding is correct.
 
0
Hi there, if you check the HHS OIG's list of legal actions you should be able to find some cases that are linked directly to diagnosis codes. https://www.justice.gov/opa/pr/hear...illion-settle-common-law-and-false-claims-act

The United States alleged that, from Jan. 1, 2017, through Jan. 31, 2021, Eargo included unsupported hearing loss-related diagnosis codes on claims for hearing aid devices that Eargo submitted to the FEHBP and on invoices — called superbills — that Eargo provided to FEHBP beneficiaries to obtain reimbursement for such devices from the FEHBP.
Click to expand...

Other cases may not be as clear but usually the medically unnecessary treatment cases required intentional use of incorrect diagnosis codes to get paid.

As with all coding whether errors can have legal repercussions will depend on the effect of the error and the reason for the error.

Take a straight forward example where the doctor accidentally selects a diagnosis code for left knee but bills and is paid for the medically necessary treatment of the right knee. That's an error, but the doctor isn't going to get into legal trouble for the dx mistake because it wasn't intentional and it didn't result in an improper payment.

To look at the other extreme, if the doctor says "I want to get paid for this service, but the diagnosis isn't covered. Therefore I'll put a different diagnosis on the claim so I will get paid," that does expose them to legal repercussions because they're intentionally using the wrong dx code in order to get paid. (I'm not going to use the F (fraud) word because that requires a criminal finding of guilt.)

Somewhere in between you have providers who never say they're using the wrong codes on purpose but their improper code selection results in overpayments. That could also result in legal repercussions. Another problem could arise if the payer's system doesn't catch a diagnosis code/service error and the practice starts accumulating overpayments.
 
0
jkyles said:
Hi there, if you check the HHS OIG's list of legal actions you should be able to find some cases that are linked directly to diagnosis codes. https://www.justice.gov/opa/pr/hear...illion-settle-common-law-and-false-claims-act



Other cases may not be as clear but usually the medically unnecessary treatment cases required intentional use of incorrect diagnosis codes to get paid.

As with all coding whether errors can have legal repercussions will depend on the effect of the error and the reason for the error.

Take a straight forward example where the doctor accidentally selects a diagnosis code for left knee but bills and is paid for the medically necessary treatment of the right knee. That's an error, but the doctor isn't going to get into legal trouble for the dx mistake because it wasn't intentional and it didn't result in an improper payment.

To look at the other extreme, if the doctor says "I want to get paid for this service, but the diagnosis isn't covered. Therefore I'll put a different diagnosis on the claim so I will get paid," that does expose them to legal repercussions because they're intentionally using the wrong dx code in order to get paid. (I'm not going to use the F (fraud) word because that requires a criminal finding of guilt.)

Somewhere in between you have providers who never say they're using the wrong codes on purpose but their improper code selection results in overpayments. That could also result in legal repercussions. Another problem could arise if the payer's system doesn't catch a diagnosis code/service error and the practice starts accumulating overpayments.
Click to expand...
I appreciate the answer and will search the site you provided. Our situation seems to be where there is intentional (via recognized EMR inadequacy) use of incorrect dx codes. It is not being done to get coverage. It seems like this is going to lead to denials and delay in payment more than any legal issue as the CPT billing levels and modifiers are not the issue.

I'd be interested in hearing if anyone knows of legal repercussions of only diagnostic coding errors.
 
0
LauraNewYork said:
Our practice has recently changed the method that claims are sent out. Currently the providers chose the level and the dx codes 😟. Biannual auditing of the providers was put in place. Coders are not allowed to make changes to the submitted level or submitted dx codes. Coders add modifiers as needed. The coders have strenuously objected to the change, knowing that it would cause a lot of back end work.

As expected, we have seen a huge number of denials related to dx code errors. I just discovered that our EMR does not allow the providers to put the dx codes in a specified order, rather the codes are randomly applied to the charge. I have completed multiple searches regarding the legal repercussions of incorrect dx coding, but am having difficulty teasing out legal repercussions of incorrect dx coding as a separate issue from level or modifier coding. EXAMPLE: a charge went out with gastroenteritis as the primary code when the patient was actually seen for breast cancer. The breast cancer was the 5th listed code. Another charge went out with multiple R codes when they were seen for a cancer evaluation which wasn't even listed on the charge.

I would greatly appreciate any input regarding the legal repercussions of incorrect dx coding when billing level and modifier coding is correct.
Click to expand...
Sounds like your providers/practice are going to learn a lesson the hard way. Decreased revenue and increased denials are obviously in your favor. Good Luck. Years ago a company that I used to work for switched to an EMR thinking that the EMR could choose the E/M and the providers could choose the ICD.9 codes. Neither turned out to be true. It was so bad that the company had to change their plans and keep the coders.
 
0
Orthocoderpgu said:
Sounds like your providers/practice are going to learn a lesson the hard way. Decreased revenue and increased denials are obviously in your favor. Good Luck. Years ago a company that I used to work for switched to an EMR thinking that the EMR could choose the E/M and the providers could choose the ICD.9 codes. Neither turned out to be true. It was so bad that the company had to change their plans and keep the coders.
Click to expand...
Thank you. The CFO doesn't seem to be concerned about anything else as long as the charges go out by month end.
 
You must log in or register to reply here.
Top