BUSINESS

  coding strategy

Beyond “Billing”

The business side of coding and compliance

JOHN RUMPAKIS, O.D., M.B.A.

I don’t get upset very often. I’m generally a calm, collected individual who likes to deal with facts and figures. I do have my passions, of course, which exist outside of the world of medical coding and compliance — cooking, wine, and bourbon. But one thing that really gets me going is when people refer to this area as “billing and coding.”

It’s important to understand that codes weren’t developed just for “billing,” and we can’t just casually use these codes in any manner we want.

HIPAA guidelines

In the U.S., one of the prevailing laws that healthcare practitioners must abide by is HIPAA. HIPAA requires physicians to follow the rules of the ICD and the CPT systems. Let’s look at some specific guidelines:

► Each physician in the U.S. today is legally bound by HIPAA to follow two standards for providing professional services and medical devices to a patient. These are described in the AMA’s CPT Codes as well as in the World Health Organization’s ICD-9 and ICD-10 codes. Compliance is not optional, and it is not based upon revenue requirements of the practice.

► CPT codes are used to accurately describe to the whole world — meaning carriers, courts, healthcare organizations, public health departments, etc. — the very specific, delineated services that are provided during a patient encounter. A single five-character code describes the complexity, severity, location, procedure, structure(s) evaluated, associated rules and guidelines implied by using that code that a physician attests to under the penalty of perjury with his signature. In fact, the CPT codes used are the only legal method to represent the contents within the medical record.

► If a physician misrepresents services provided (by using an incorrect code) and the courts and carrier-adjudicating bodies see the difference between the services represented by the CPT code used and what was actually written in the medical record itself, it is a legal and a business issue.

Modifying a medical record after the patient encounter is often tantamount to fraud, so the physician must know how to properly record the encounter — everything from patient history, physical findings, assessment and continuing plan of care the first time he sees that patient. If the physician miscodes or mischaracterizes the patient encounter in any way, he is subject to both civil and criminal actions, as well as additional actions taken by the insurance carriers.

► Both the ICD-9 and ICD-10 codes are used around the world to classify the incidence and prevalence of conditions. Moving from the ICD-9 to the ICD-10 system is going to be a complex process for physicians. We are moving from a classification system of roughly 18,000 codes to one with 140,000 codes, and, with the increased specificity of the ICD-10, there is much more opportunity for a medical record to fail if the physician is not paying attention to the detail required in the medical record.

It is not just converting an ICD-9 to an ICD-10 code; if a physician doesn’t record things properly, omits key pieces of information, misrepresents a diagnosis or attaches the wrong diagnosis to a patient record, not only does he or she face significant consequences, but the patient medical record itself is compromised, and the patient can suffer as well.

Legal Ramifications

Mistakes can be costly. To give you an idea of how seriously the federal government takes this, on the standard CMS-1500 form, there are six lines to represent six different services provided. Each line is worth up to $10,000 in civil penalties if the services are mischaracterized.

I sit on the advisory boards of two different insurance carriers, as well as provide expert witness and consultative services to O.D.s and M.D.s when they are the subject of a fraud investigation. Thankfully, most fraud is unintentional, and the offending physician often didn’t know the rules or just let his or her staff code the encounter. Yet, the penalties are still significant: it is not uncommon to see audit recoveries for carriers in the hundreds of thousands of dollars per practitioner.

Your responsibility

Coding an encounter properly is a physician’s legal responsibility. A code is not developed just for the purposes of “billing.” This is a significant and material part of every physician’s legal responsibility to provide care. It is the only legal representation of the services provided and, if not done right, can be a significant business issue for the practice. OM

DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.