With patients backed up in the waiting room and an important meeting in an hour, family practitioner John Langfeld, M.D., doesn't relish the task of figuring out which of five codes he should choose for a routine office visit.
"I've got all these patients (waiting) and I sort of remember something from the '95 HCFA guidelines, but now somebody wants me to use other guidelines and I'm increasingly lost," Langfeld says.
Fortunately, Health Associates of Kentucky in Lexington, where Langfeld is chief medical officer, started a comprehensive compliance program about six months ago where the staff is being trained to become better coders. The undertaking involves nurses, receptionists and all 50 doctors, including Langfeld.
Across the country, physicians like Langfeld are increasingly bewildered by the onerous task of correctly coding patient encounters for both government and private payers. But rather than throw up their hands, savvy physicans are investing in training, experienced personnel and compliance programs to make sure they receive proper reimbursement and to avoid the possibility of investigation and prosecution.
The extent of improper coding by doctors is difficult to estimate. But coding errors by doctors to Medicare alone amounted to $1.5 billion in 1999, $1.7 billion in 1998 and $1.1 billion in 1997, according to a February 2000 report by HHS' inspector general's office.
The report found that doctors accounted for the vast majority, in terms of dollars, of errors submitted to Medicare. Further, the report said, for most of the coding errors found, doctors were overbilling.
Industry observers acknowledge coding accuracy is a problem but say the issue involves undercoding as well as upcoding.
"Errors and omissions occur every day, and (doctors) don't even know that they're making those errors," says Debi Croes of the Croes Oliva Group, a practice management firm in Burlington, Mass. Contrary to the inspector general's findings, Croes says that most of the doctors she works with "deliberately undercode" in the mistaken belief that they will reduce the possibility that they may be investigated. But ironically by doing so, they draw attention to themselves, she says.
One cause of inaccurate coding is that practices use out-of-date codes, says Susan Garrison, senior manager at 3M Health Information Management in Atlanta and president of the American Academy of Professional Coders. Garrison says many physicians use the current code but apply it incorrectly, for example, billing for a colonoscopy when they should be billing for a colonoscopy with polypectomy. Mistakes such as these add up in two ways. First, the doctor may get paid too little, and second, it takes considerable time and money to resolve an incorrect code that has been submitted and rejected by the payer, she says.
Adding to the problem of trying to correctly code is the trend by managed care companies to approve payment for only certain kinds of diagnoses, says Gail Smith, program chair of health information management at Cincinnati State Technical and Community College. For example, a patient complains of chest pain and the doctor runs an EKG, which turns out normal. The doctor determines that the cause of the pain is anxiety but because that's not an approved diagnosis, doctors look for something else on the approved list in order to get paid. In such a case, the "correct" coding is based on getting paid rather than on medical facts, which can lead to charges of fraud later down the road, she says.
Concerns about fraud have led the American Health Information Management Association, a Chicago-based professional organization with 38,000 information management professionals, to strengthen its standards of ethical coding. The new standards advise members that "diagnoses or procedures should not be inappropriately included or excluded because the payment or insurance policy coverage requirements will be affected" and that members should remember that "it is unethical and illegal to maximize payment by means that contradict regulatory guidelines." Although previous guidelines did broach those subjects, the new guidelines are more explicit.
AHIMA offers consulting services, seminars and books on the topic. It addresses the educational process for doctors and support staff, set up a compliance committee and established a toll-free line for questions about a regulatory issue, an internal audit procedure and other issues.
While some practices have taken to buying coding software programs as a way to quickly and effectively help them code more accurately, the technology is only as good as the person using it, says Rita Scichilone, AHIMA practice manager, coding products and services.
Smith agrees. "I've never met a software program that I thought was trustable," Smith says. "You still need someone who's knowledgeable to analyze the software" and how it interacts with the data.
Both Scichilone and Smith say that the most effective step is to invest in people. For a start, consider hiring registered health information technicians (RHIT) and registered health information administrators (RHIA). Students attend college for two years to become an RHIT and four years to become an RHIA, after which they take a national registry exam. In the Midwest, an RHIT typically would earn $30,000 to $40,000, Smith says. Although salary levels for someone without RHIT training were not readily available, she says they earn thousands less.
Apparently, many healthcare providers have caught on; Smith says all of her students in the past few years have had at least one job offer in hand upon graduation, despite their higher salaries relative to regular medical office staff.
An even more ambitious and effective route is to establish a compliance plan, Scichilone says. Compliance plans basically document what the inspector general's office recommends to healthcare providers as the correct procedures for billing, what to do when finding errors, how to educate staff members and similar topics.
Health Associates spent the past three years developing its own compliance program, Langfeld says. Health Associates' doctors work in 15 offices in central and southwest Kentucky. The practices focus on primary care and urgent treatment.
As part of the Health Associates program, all physicians must go through a CD-ROM program replete with mock encounters with patients, tests and other educational devices to teach the basics of good coding. The software tells the compliance committee who finished the program. Each month, there is also on-site compliance training that is more personal and interactive. Internal audits uncover doctors and staff who are not up to snuff, and they participate in special training. If their accuracy does not improve, they can be fined, Langfeld says.
Because the program was only firmly established six months ago, concrete results are not yet in, Langfeld says. But he believes the practices is making tremendous strides.
"It (a compliance program) is an investment you can't afford not to do because of the liability," Langfeld says.
Coming up shortSome examples of incorrect evaluation and management coding by physicians on Medicare claims
Source: HHS' inspector general's office, "Improper Fiscal Year 1999 Medicare Fee-for-Service Payments"