Documentation and Coding

Compliance experts agree that the biggest risk area is coding and billing for Medicare, Medicaid and insurance reimbursements. Sometimes physicians don’t comply with these rules because the codes for procedures are confusing and time-consuming to figure out and document. Some physicians have a tendency to under-bill when they aren’t certain about their documentation of a more expensive procedure. A physician might say, “‘I’m just going to under-code; then I don’t have to worry about whether I’ve documented it correctly or not. I’ll just bill the lower code,’” explained Tray Dunaway, a surgeon and compliance guru based in South Carolina. The problem with under-billing – which is also considered fraud because you’re billing for a service you didn’t perform – is the physician isn’t reimbursed at the proper level for the services provided.

Another problem, Dunaway said, is that physicians sometimes resent surveillance. They might think, “‘Why should I have to prove I did anything? Can’t you just take my word for it?’ For the vast majority of physicians you can, but there are people out there who have abused that,” said Dunaway, who has developed a coding system for physicians. However, he maintains that it’s easier to be in compliance than out of compliance, and that once physicians understand the rules precisely, coding correctly can take less time than coding incorrectly. Plus, chances are the right code is a higher-paying one.

Physicians can hire a third party to develop a plan for billing and coding tailored to their practice and to train their staff on how to use it. “A training session shows the staff the doctor cares and recognizes there might be a problem and lets the world know they’re fixing the problem. That transparency is good,” said Vincent DiCianni, owner of Affiliated Monitors in Boston, a company that specializes in compliance programs. “It helps boost morale and also increases people’s awareness.”

Next: Delegating Care