Tips on Avoiding Fraud
and Abuse Charges
Renewed attention has been drawn toward fraudulent coding by recent activities of the Office of the Inspector General (OIG). Four early investigations of teaching hospitals through PATH (Physicians at Teaching Hospitals) audits resulted in settlements in excess of $65 million. With investigations moving toward individual physician’s practices, it is important to review common areas of miscoding, up-coding, and unbundling to reduce one’s risk in an audit.
Reducing Risk
Evaluation and management (E&M) coding has received extraordinary attention by auditors. A combination of confusing rules, resistance to implementation, and the interpretation of better-defined rules (retroactively) has led to the common identification of errors when auditing outpatient records. Principal areas of misunderstanding have included differences between new patients and consultations, as well as determining which level of service was provided.
Identification of a consultation requires several components. First, a physician must request your service. Second, there must be written documentation of this request (described as a “request for consultation” rather than a “referral”). Last, the findings and recommendations from the consultation must be communicated back to the requesting physician in the form of a chart note. Documentation of the written request can come from either the requesting physician or the consultant. Although the consultant may initiate diagnostic tests or treatment, a transfer of care of the patient precludes a consultative service.
Since reimbursement of consultations can be one-third greater than for a new patient, this may attract auditors. However, as subspecialists, neurosurgeons typically use consultative codes more often than primary care physicians do.
Additional attention has been given toward up-coding the level of service. Although the work for a given level of service is frequently performed, the documentation must support the billed level of service. The three key components of documentation include the history, examination, and medical decision.
For example, the level of service is determined using a complex grid that identifies the number of historical questions asked, the number of examination items performed, and the number, complexity, and risks of diagnostic and management options considered. Profiles of physician utilization have identified “outliers” whose coding frequency differs from the norm.
Some physicians have responded by either undercoding or artificially creating a “normal” distribution of code usage. Although it may not be fraudulent to “underbill” for a higher level of service provided, it does result in reduced reimbursement for outpatient services that make up a greater proportion (approximately 25 percent) of total practice income. Since neurosurgeons typically see more complex patients and treatments often carry significant risks, one might expect a greater utilization of higher levels of service by a neurosurgeon.
Unbundling: An All Too Common Error
Although less attention has been given to surgical coding, there are common areas of miscoding from unbundling that have been identified. The term “unbundling” refers to coding additional procedures considered integral components of an already coded primary procedure. The Correct Coding Initiative has led to software that precludes payment for unbundled codes; however, some carriers may not use such systems. It is important to realize that payment for services does not legitimize incorrect coding. In fact, insurers are increasingly reviewing past claims for unbundling in an effort to recover overpayments
Common illustrations of unbundling can be identified in most areas of neurosurgery. For example, ventricular decompression (61107) is considered a part of major craniotomies. Similarly, frame placement (20660) is considered a part of stereotactic procedures (61720-61793). Moreover, dose-pllanning was considered in valuing stereotactic radiosurgery (61793) and should not be coded separately as 61795. Although fluoroscopy for localization or instrumentation placement is included in major spinal procedures, the use of computer-navigational systems can be coded separately as 61795. Finally, posterior lumbar interbody fusion (22630) includes the laminectomy, facetectomy, and discectomy (63047, 63030) required for the arthrodesis.
Neurosurgeons should take notice that there is an acute awareness of fraud and abuse in coding, with physicians fearing financial and criminal penalties. Although many instances of miscoding likely reflect incorrect interpretation of the rules, the OIG does not accept ignorance as an excuse.
However, the OIG does acknowledge that the application of coding requires continuous education, and has looked favorably upon serious attempts at education through self-instituted compliance programs. Since the physician is ultimately responsible for correct coding, it behooves all practices to recognize the importance of accurate coding and utilize the educational programs provided by medical specialty societies, such as the AANS, to facilitate improved coding practices. To learn more about AANS-sponsored courses on coding and reimbursement, see page 9. To register for a course, call (888) 566-AANS.