Physician coding and billing risks

Health Care Compliance Association (HCCA)
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Health Care Compliance Association (HCCA)

CT magazine (August 2022)

Medical school curriculum is heavy in anatomy, physiology, biochemistry, pathology, and clinical rotations or clerkships. There is very little, if any, instruction on proper coding and billing for professional services. The years a physician spends during residency might result in a little training in coding and billing, but typically it is not extensive. After residency, a physician is thrown into the real world of compliance risks associated with coding, billing, and documentation. Some physicians report the rules don’t make sense. Other clinicians report being too busy with patient care to have time to learn billing and coding rules. However, ignoring some common coding and billing risk areas can result in questionable compliance practices, potential audits, and, in some cases, enforcement.

What are some of the most common coding, billing, and documentation compliance risks that physicians face today? There are many, but let’s take a closer look at two common areas: upcoding and misuse of modifiers.

1 U.S. Department of Health & Human Services, Office of Inspector General, “York Surgical Associates, Dr. Daniel Growney, and Dr. Ye Ye Agreed to Pay $43,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Upcoded Claims,” April 19, 2022, https ://oig.hhs.gov/fraud/enforcement/york-surgical-associates-dr-daniel-growney-and-dr-ye-ye-agreed-to-pay-43000-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-upcoded-claims/.
2 U.S. Department of Justice, U.S. Attorney’s Office for the Western District of Texas, “Justice Department Reaches Settlement Agreement with Physicians Group in El Paso Over Allegations of Violating the False Claims Act,” news release, June 23, 2021, https://www.justice.gov/usao-wdtx/pr/justice-department-reaches-settlement-agreement-physicians-group-el-paso-over.
3 Centers for Medicare & Medicaid Services, “1995 Documentation Guidelines For Evaluation and Management Services,” accessed June 2, 2022, https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf.
4 Centers for Medicare & Medicaid Services, “1997 Documentation Guidelines for Evaluation and Management Services,” accessed June 2, 2022 https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf.
5 American Medical Association, “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes,” accessed June 2, 2022, https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.
6 Centers for Medicare & Medicaid Services, “Chapter 12 - Physicians/Nonphysician Practitioners,” § 30.6.1, Medicare Claims Processing Manual, Pub. 100-04, revised March 4, 2022, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.
7 U.S. Department of Justice, U.S. Attorney’s Office for the District of Massachusetts, “CareWell Urgent Care Center Agrees to Pay $2 Million to Resolve Allegations of False Billing of Government Health Care Programs,” news release, March 29, 2019, https://www.justice.gov/usao-ma/pr/carewell-urgent-care-center-agrees-pay-2-million-resolve-allegations-false-billing.
8 U.S. Department of Health & Human Services, Office of Inspector General, “Audit of Medicare Emergency Department Evaluation and Management Services,” accessed June 2, 2022, https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000612.asp.
9 OIG Compliance Program for Individual and Small Group Physician Practices, 65 Fed. Reg. 59,434, 59,437 (October 5, 2000) , https://oig.hhs.gov/documents/compliance-guidance/801/physician.pdf.
10 U.S. Department of Justice, U.S. Attorney’s Office for the Northern District of Georgia, “Dermatology Physicians and Practice to Pay $1.9 Million to Settle False Claims Act Investigation into Overbilling Medicare for Evaluation and Management Services,” news release, April 18, 2016, https://www.justice.gov/usao-ndga/pr/dermatology-physicians-and-practice-pay-19-million-settle-false-claims-act#:~:text=ATLANTA%E2%80%94The%20U.S.%20Attorney's%20Office,to%20settle%20claims%20that%20they.
11 U.S. Department of Health & Human Services, Office of Inspector General, “Dermatologist Claims for Evaluation and Management Services on the Same Day as Minor Surgical Procedures,” accessed June 2, 2022, https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000577.asp.
12 U.S. Department of Health & Human Services, Office of Inspector General, “Utah Pain Doctor and Medical Practice Settle False and Fraudulent Medicare Claims Case,” July 21, 2017, https://oig.hhs.gov/fraud/enforcement/utah-pain-doctor-and-medical-practice-settle-false-and-fraudulent-medicare-claims-case/.
13 Centers for Medicare & Medicaid Services, “Medicare Drug Screen Testing,” MLN Matters, SE1105, revised April 28, 2016, https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/se1105.pdf.

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