Coding Dilemmas (Our first reader-contributed post)

Rohan D’Souza of D’Souza & Associates generously provides the following information on medical coding issues. Rohan is Vice President of D’Souza & Associates in Hockessin (and a prospective DMGMA member.) Please feel free to email educational articles to me any time at rick@kingforms.com. Please feel free to post your reaction and related experience to Rohan’s piece. By the way- Happy Thanksgiving everyone!

======Undercoding-Should You Be Afraid?

I had come across a physician who consistently was undercoding so as not to initiate a Medicare audit. He had heard many horror stories about audits and did not want to be a part of it. If I undercode, he thought, I’m getting paid and staying under the radar. I’ll just have to see a bit more patients to make up for the lost income. Actually, his undercoding could be deemed Medicare fraud.
Many physicians are in this category and often downcode E & M claims to avoid claim rejections and increased inspection from payors. Based on Medicare compliance regulations, undercoding can result in an audit just the same as overcoding. However, I have yet to hear of a case in which CMS has come back to audit and reimburse for undercoding.
Undercoding also destroys any proper reporting of services that the physician has actually performed. This physician may have been at a low level, when in fact, their data for services performed should show a nice bell shaped curve. Since CMS uses claims data to revise annual reimbursement rates, undercoding can seriously influence and lower payments.
Proper coding and billing is necessary to insure maximized revenues and increased profits. Many providers do not have the proper knowledge of the coding system and also do not have the proper billing processes in place. The coding is often left to the office staff who have very little training in coding guidelines. Many times the staff will miss procedures based on the fact that they are not the ones actually providing the service and the physician does not properly communicate what they did.
The key phrase that should be kept in mind is: “Code what you document and document what you code.” If a physician has documentation of a certain level of service and codes to that level, he/she should never be afraid that he is undercoding or overcoding. When a physician provides a service, he/she is entitled to the proper compensation as set by the insurance payors. I have seen some practices coding at a higher level and CMS comes back to them saying that they their billing patterns are outside the averages of their peers. These practices have seen an audit or two and have passed them with flying colors. They happen to code at a high level because they deal with patients in critical care and of a high complexity.
It is a big help when you have a certified coder, who has gone through Medicare auditing education, look at sample notes to see if they support the level of service billed. The precision of the coding and billing can also be increased by utilizing an outside billing company.

Myths of E and M coding
1 – All E and M visits are billed based on time (5 minutes for a level II, 15 minutes for a level III,etc)
2 – Nurses notes cannot be attached to the physicians’as part of the service
3- A program will tell me what to code
4 – If my office staff incorrectly codes something it is not my fault as a provider
5 – Procedures and E & M visits cannot be billed together on the same day

If you have any coding or billing questions, or need consulting or billing advice, please feel free to call me at 302 239-4743.

Rohan D’Souza, BS, CPC-CARDIO, GASTRO, PAYOR, E/M, is the Vice President of D’Souza & Associates, a healthcare management company based in Hockessin, Delaware. He has successfully gone through Medicare Audit education and classes for the last 5 years. He is a certified coder and has passed the hospital payor exam, specializing in Cardiology, Pulmonary, and Gastroenterology billing.

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Tags: D'Souza, Happy Thanksgiving, Medical Billing, medical coding, practice management, reader-contributed article, Rohan D'Souza, undercoding