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HIM & Heard

Living With the Black and White Problems of Grey Codes

Published August 10, 2012 8:11 AM by Stephanie Cecchini

In recent years, the government and private payers have taken a firm position on fraud and abuse. The Patient Protection and Affordable Care Act allows the Centers for Medicare & Medicaid Services to suspend payments when there are "credible allegations of fraud." It's increasingly important to avoid even the appearance of wrongdoing.

Adding fuel to the fire, in an election year, all eyes are on wasted tax dollars and high costs in health care.  Inaccuracies in the coding of physician visits are estimated to account for up to 3 percent of the medical loss ratio in commercial plans and up to 1 percent in Medicaid plans. Abuses, honest mistakes in billing for physician visits, account for estimated national losses in billions each year.

How can this be true when the vast majorities of physicians are committed to billing accurately and are legitimately surprised when mistakes are uncovered?

Evaluation and Management codes, the codes that bill for office visits, are subjective in nature. From the aspect of medical necessity, the correct level of service is determined simply by how sick a patient is. Conditions that pose an immediate threat to life or limb qualify for the highest code level, whereas patients with minor or well controlled problems are at the lowest; however, peers may see the same patient and assuming the same diagnosis may still argue how sick the patient really is.

Beyond medical necessity aspects, the rules that govern documentation requirements are also in many ways subjective. Reproducible audit results between unrelated documentation requirement auditors are not unfailingly prevailing. Properly trained and certified auditors may agree on the actual code selection better than 90 percent of the time; however the means and measurements of their conclusion can be different upwards of 50 percent.

This is partly due to the choice of two distinct guidelines used to measure the correct level of service. CMS'  "1995 Documentation Guidelines for Evaluation and Management Services" or "1997 Documentation Guidelines for Evaluation and Management Services" are the criteria used to determine whether documentation supports the level of service billed. CMS has instructed all Medicare carriers to use whichever one is more favorable for the physician. This means, on a claim by claim basis, the Evaluation and Management results are based on one of two sets guidelines and the judgment of the coder. Of larger concern is the various interpretations of the guidelines, and the vague criteria within them.

Complicating things further, a qualified coder may review a document and establish that a comprehensive service was rendered; however, a medical review may find the same document lacking in necessity. A comprehensive service may be a physician's personal art and style of practice but may not be considered necessary and billable by a majority of his or her peers. For example, a comprehensive history and physical may not be necessary to repeat on a two week follow-up visit to check the patient's normal blood pressure.

The worst thing a physician can do is to wait until the 11th hour of an audit to determine an audit response game plan. Just because someone disagrees with your code selection does not mean they are right. Evaluation and Management codes are notoriously subjective and overpayment requests may be overturned in an appeal with the right response to the initial audit results. Physicians who are unemotional about their coding are often times on stronger ground with solid and objective reasons for their coding. As a proactive measure, having an advance familiarity with clinical examples from creditable sources and specialty associations can be helpful. These are powerful because they establish objective measures where there is room for subjectivity. The most credible medical coding review comes from an unbiased peer and an established compliance expert.

Typically, the most effective way to ensure correct coding is with the help of an Evaluation and Management compliance expert. A few minutes of coding and documentation requirements education can prevent big problems from overpayments and losses from inaccurate coding.


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