EHRs may reduce medical liability for some errors, but could create new forms of medical liability and expose existing liability issues, says report.
You’re not only losing revenue—you’re also coding improperly.
CMS data from previous years shows that medical practices undercodè E/M claims to the tune of over $1 billion annually—that’s money that physiciáns could have collected based on their documentation, but forfeited because they reported a lower-level codè than they should have. But remember that your responsibility as someone who submits claims to Medicarè is to codè based on the documentation—anything else is incorrect coding.
If you’re one of the practices that’s downcoding claims, take note of the following reasons that you should codè based on your documentation rather than undercoding.
Could You Be Triggering an Audit?
The number one reason that many practices undercodè is because they don’t want to “trigger an audit.” However, coding all low-level E/M codès is sure to get a payer’s attention, because the claims reviewers will be wondering why you never offer high-level evaluations to your patients.
When claims reviewers review “bell curves” to determine whether a practice is coding outside the norm, they aren’t just looking for upcoding—they are looking at trends across the board. This means that a practice with all 99212s and 99213s will be vulnerable, because nearly every practice sees more complex patients requiring high-level E/Ms at least once in a while. If an auditor reviews your rècords and determines that you’re deliberately downcoding claims, they’ll conclude that you’ve been coding improperly.
Consider Compliance Implications
If you’re deliberately undercoding your claims to stay under the radar, you’re technically violating the False Claims Act because you are knowingly submitting a false claim. “It’s a violation just as much as deliberate upcoding is a violation, but the government most likely isn’t going to pursue it because ultimately it savès the Medicarè program money,” says John B. Reiss, PhD, JD, a health care attorney...
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Amidst an AMA lawsuit, the FTC appears to take a wait-and-see approach.
After a year’s worth of extensions of the Red Flags Rule, medical practices were ready to buckle down and ensure that their plans were in place, because the rule was set to take effect on June 1.
However, just days shy of that deadline, the Federal Trade Commission (FTC) announced that it would be delaying enforcement until Dec. 31, 2010, “at the request of several Members of Congress,” according to a May 28 FTC news release.
Under the Red Flags Rule, “certain businesses and organizations — including many doctor’s offices, hospitals, and other health care providers — are required to spot and heed the red flags that often can be the telltale signs of identity theft,” according to an article on the Federal Trade Commission’s Web site.
To comply with the Red Flags Rule, covered entities are expected to create a written red flags program to prevent and detect potential identity theft cases.
According to the FTC, the rule applies to businesses that qualify as creditors or financial institutions, and the FTC’s broad definition indicates that it applies to many medical practices. “Health care providers are creditors if they bill consumers after their services are completed,” the FTC Web site says. “Health care providers that accept insurance are considered creditors if the consumer ultimately is responsible for the medical fees.”
However, simply “accepting credit cards as a form of payment does not make you a creditor under the rule.”
Congress requested the delay in part to “pass legislation that will resolve any questions as to which entities are covered by the Rule,” the FTC press release indicated. “Congress needs to fix the unintended consequences of the legislation establishing the Red Flags Rule — and to...
Heads up: These vaccine admin codes are excluded from incident-to requirements. Incident-to rules don’t always apply to diagnostic services, but many medical practices aren’t aware of that. And based on a new wave of scrutiny directed toward incident-to claims, you should know physician supervision rules inside and out. A recent audit from the HHS Office of the Inspector [...] Related articles: