Compliance and Physician Coding: Top 10 Problem Areas

February 5th, 2013 / By Barbara Aubry, RN

When I first started thinking about this topic, a million things came to mind. Should the oldest compliance challenge—what is most expensive—be number one on the list, or should the top issue be the one that could cause the most problems?  Having to narrow it down to ten became more of a challenge than I anticipated. Here goes—my opinion of the Big Ten compliance challenges facing physicians in 2013.

  1. Documentation (or the lack thereof) –Those of you who read my blogs know my position on this, but let me say it again: As the old adage goes, “if it wasn’t documented, it didn’t happen.” This is true in paper as well as electronic records. And even if you are using an EMR that literally will not let you enter another digit until you complete a document step, it’s still a problem. I have seen cloned EMR documentation that says the patient had the same flu at every visit since 2009. And the OIG has noticed too. Beware the cloned EMR. Remember, coders populate your claims with your documentation and the RAC and other auditors are watching intently.
  2. Big data – Everything you add to an EHR/EMR is saved and aggregated for multiple purposes. One recently recognized use is clinical and pharmaceutical research. Now, they have access to tons of data they would never have been able to gather in trials. The importance of your accurate documentation of an encounter not only affects the present patient visit and its coding, but also has potential impact on future research and clinical outcome expectations.
  3. Electronic Medical Records/ Electronic Healthcare Records – Even though you really don’t want to leave your paper charts, the industry is making it mandatory. So how do you know which product to invest in? Which works best for your practice? Who should you trust? Which vendor will stand by their product? Where can you find the product with the most compliant content and coding rules?
  4. Prepayment audits and coding accuracy – Lousy documentation results in lousy coding. I suspect CDI specialists and coders are tired of seeing “‘probable or potential sepsis” thrown in with every urinary tract infection that comes through the ED doors. What does the poor coder do with this? He or she is left to try to determine if you were serious or figured you would add it in case it actually turned out to be true. The terminology physicians use greatly impacts coding. And with the growth of computer-assisted coding (CAC), every word counts. Over- or “upcoding” is not to your benefit especially now, with prepayment audits in full swing. This does not mean you should under-code. The goal is to say what you mean and mean what you say when you document.
  5. Medical necessity – It is so boring to have to check medical necessity rules, but it’s still the gold standard. At least for Medicare outpatient services, you have the option to check against their policies. Although without easy electronic access, it is cumbersome. (Wish list: fast, accurate and reliable electronic access to medical necessity policies. Payers—are you listening?). Inpatient is more challenging because CMS does not make it clear which utilization standards they use to make their decisions. Regardless, medical necessity compliance can mean the difference between claims payment and denial. And since the diagnosis used to check medical necessity comes from your orders, be sure you document carefully so coders can produce an accurate claim.
  6. Evaluation and Management (E/M) rules – What can I say? It’s true that we still have two sets of rules: the 1995 and 1997 Document Guidelines. Some physicians are really good at using few words to comply with criteria while others feel compelled to hit every bullet point. If you have the misfortune to be audited, the bottom line is still “medical decision-making.” Nurse auditors  are concerned when they see a full ROS and exam of every body area for a complaint of “ingrown toenail.” That type of documentation will never get you to a level four or five—so be sure to document what is necessary to support the medical decision you likely formulated within the first 60 seconds of seeing the patient.
  7. Waste, fraud, and abuse – The Fed and the OIG are all over this. Remember, every entity submitting a claim to a federal program is subject to review: according to CMS, over a billion claims are submitted annually for payment. Of that number, two-thirds are submitted by physicians. Be sure the coding for your practice is accurate and compliant—even if you use a billing service. Don’t expect the OIG will ignore you if you use a vendor. Be sure the coding and billing company you contract with is doing the right thing on your behalf.
  8. Lack of a compliance plan – Hospitals are not the only providers who must have written processes and procedures in place. Your compliance plan needs to help flag inappropriate behavior in an effort to avoid or correct potentially improper conduct. It can be a lifesaver if you are ever faced with an OIG audit or investigation. Be sure your compliance plan includes coding. Ensure your coders are educated, trained and provided with the necessary resources required to accurately do their job. Back in the day, I taught physicians how to code evaluation and management services. Unfortunately, many attended with their coder, who brought their office’s latest coding books—most of which were at least two-to-three years out of date!
  9. ICD-10 – Right, you must adapt to a new diagnosis coding system. And from what I’ve seen, some physicians struggle with assigning ICD-9 codes now. Perhaps given the opportunity to learn a new system they will improve? ICD-10 is not the devil system some portray it to be. It’s actually more clinician-friendly because it’s more precise. You can accurately identify patient acuity, which will result in higher reimbursement. Both coders and physicians need to be trained. Most use the same subset of diagnosis codes in their daily work, so the learning is finite. Focus on the codes your practice uses. Offer time and reimbursement options to train your in-house coders. If you use a billing service, have them demonstrate their accurate, ICD-10–ready system—don’t simply take their word for it. Compliance is your responsibility.
  10. Behavior modification – Most of us don’t like change. We are creatures of habit and that’s okay. But consider this—in sports, most winning teams have a positive attitude and believe they will be triumphant. The San Francisco 49ers and the Baltimore Ravens went to Super Bowl XLVII because they strongly believed they could get there, and the Ravens proved to be the most positive thinkers—even in a blackout!  If you aren’t a fan of the changes in healthcare or technology, try to have an open mind and believe it will work for you. You have a cell phone, right? Can you imagine life without it? Five years from now you will be used to EHRs, computer-assisted coding and documentation changes. ICD-10 will not be new anymore. You can comply with whatever is expected because you are flexible and smart—and you can get there.

Barbara Aubry is a Regulatory Analyst with 3M Health Information Systems.