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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...