The medical practice today relies on medical claims to be correctly coded and billed. Improper medical claims filed result in loss of revenue to a medical facility, fraud investigations, financial sanction, disciplinary action, and exclusion from participation in government programs (Adams, Norman, & Burroughs, 2002). The encounter with a patient involves a series of actions. First the physician sees the patient and then signs documentation of the visit. Codes are assigned based on the documentation provided by the physician. The encounter is then billed from the codes assigned according to the documentation.
The procedures performed must be linked directly to the services that are being billed. Medical record documentation is evidence of coding and justification for billing. Failure of the physician to appropriately document the medical records could result in improper coding and erroneous billing. If the procedure and diagnosis are not supported from the documentation then there is a risk of the claim being denied which could result in delays in receiving payments, reduced payments, fines, and ultimately the loss of the physicians license to practice medicine (Adams et al. 2002). The documentation provided in the medical record is viewed as the basis for coding and billing determinations. To assure that the appropriate medical documentation is accurate the following steps are used (Adams et al. , 2002). 1. Practice timely, accurate and complete documentation. 2. Use appropriate diagnosis codes for examination and personal history. 3. Link appropriate diagnosis with appropriate procedure code. 4. Use modifiers appropriately.
5. Identify other insurance coverage when billing Medicare. Adams et al. 2002) states that the Office of Inspector General (OIG) recommends the following minimum compliance for medical record documentation: * The medical record should be complete and legible. * Past and present diagnoses should be accessible in the medical record. * Appropriate health risk factors should be identified. * If not documented the rationale for ordering diagnostic and ancillary services should be easily inferred by an independent reviewer. * Patient’s progress, his or her response to any changes in treatment and any revision in diagnoses should be documented. Documentation of each patient encounter should include the reason for the encounter, with any relevant history, physician examination findings, prior diagnostic test results, assessments, clinical impressions, diagnoses, plan of care, date of service, and legible identity of the observer. Compliance strategies are put in place to avoid billing errors. It is important to be familiar with the billing rules for each payer. The rules are explained in the patient’s medical insurance policy and in the participation contracts.
Payers will also update any rules or contract changes through their websites and through bulletins. The medical insurance specialist within a facility should also be familiar with payers websites, bulletins, and also to keep communications with payers representatives (Valerius, Bayes, Newby, & Seggern, 2008). The OIG has instructed physicians that the services provided should be fully documented, compliance plans be put in place to reduce coding errors, and that only medically necessary services be billed (Adams et al. 2002). According to Adams et al. (2002) the following are identified as the most common billing areas and are considered high risk areas to physicians, * Billing for items or services not provided. * Submitting claims for equipments, medical supplies, and services that are not reasonable and necessary.
* Double billing for the same service or item. * Billing for non-covered services. * Misuse of provider identification numbers. * Unbundling a multiple component service. Failure to properly use coding modifiers. * Upcoding the level of service provided. Unbundling occurs when a practice performs a multiple component (bundled) service and then bills each component as an individual service (Adams et al. , 2002). Medicare’s Correct Coding Initiative (CCI) of bundling rules is often used by medical facilities as a guideline for services included in a procedure (Valerius et al. , 2008). Upcoding occurs when a more expensive service is billed then what was actually performed.
Evaluation and management guidelines are updated periodically, the medical facility should be aware of updates and revise their coding procedures and medical documentation accordingly (Valerius et al. , 2008). The use of modifiers allows a physician to identify a procedure that has been altered by a circumstance but not changed in its definition or code. Billing codes that require modifiers should be reviewed consistently and used appropriately (Adams et al. , 2002). Audits are performed periodically to assure that fraudulent billing does not occur.
A facility may choose to perform its own audit to avoid an external audit, investigations, and to catch billing errors. An internal audit is usually performed by a staff member or a hired investigator. There are auditing tools available to assure that the proper codes are being used and that proper documentation is present in the medical record that will support the selected codes. I feel that the methods discussed are beneficial to any medical practice and should be practiced consistently.
Although in most cases billing errors are innocent mistakes, there are some facilities that do submit fraudulent claims. The internal audits should be performed regularly by a staff member that is familiar with the coding and billing process. I believe that this method would detect if there is a problem in the facility with a staff member that may not be performing their responsibilities adequately or if the individual may just need additional training. In a facility with multiple doctors it would be beneficial to catch any fraudulent behavior by one doctor.