HIM professionals are crucial in efforts to prevent fraud and abuse allegations

Biggest problem is lack of proper documentation

It’s an old story that just grows more complicated with each passing year of new Medicare coding changes and health regulations: Coding mistakes, whether intentional or not, can lead to a government investigation about fraud and abuse.

"Usually the biggest problem is the lack of proper documentation on the part of physicians or other providers," says Charles E. Colitre, BBA, president of Med-Management Group Inc. of Akron, OH. Before heading a health care compliance consulting company, Colitre worked for the FBI, supervising investigations in health care and other fields in the Northeastern Ohio region.

"Particularly in the evaluation and management codes, the documentation needs to cover enough of the required areas to justify the coding level," Colitre says. "Clinicians need to be very specific about what their impressions are and what the diagnosis is."

Strategies to prevent federal investigations into alleged fraud and abuse include having a compliance program in place that includes HIM staff.

Whenever a health system has a compliance program that is designed to prevent errors and that corrects problems as they arise, federal officials will see this as a mitigating factor in any investigation, Colitre says.

Health care facilities also should have ongoing staff training about coding changes and to reinforce policies and procedures, says Karen Scott, MEd, RHIA, CPC, CCS-P, owner of Karen Scott Seminars and Consulting Services of Bartlett, TN. Scott also is an associate professor in Health Information Management at the University of Tennessee in Memphis.

"Make sure people are up-to-date. That’s the main thing," Scott says. According to federal regulations, if a coder or health care professional could have or should have known about a policy, coding change, or regulation, then that person is held responsible for fraud or abuse that results from ignorance, Scott says.

This means HIM staff must keep up with the ICD-9 and CPT books, as well as the official coding guidelines developed by cooperating parties which include the American Hospital Association (AHA), the American Health Information Management Association, the Centers for Medicare and Medicaid Services, and the National Centers for Health Statistics. The guidelines cover both inpatient and outpatient coding.

"There are official coding guidelines available on the CMS web site and in several other places," Scott says.

Also, HIM staff are responsible for knowing information, including local carriers and fiscal intermediary rules, sent out by Medicare on memorandums, quarterly publications, and bulletins, Scott says.

The carriers and fiscal intermediaries typically have web sites that publish the rules, and they’ll send printed information to health care facilities. "But that often doesn’t make it down the trail and get to coders, so coders need to make sure they’re up-to-date on all that," Scott says. 

Another prevention strategy is for all departments within a health care system, including the HIM department, to have their own policies and procedures, Colitre says.

"Policies and procedures will ensure that the procedures that they perform and the supplies and services they render are properly captured and billed," Colitre says.

"Overall, within a health care system, those departmental policies and procedures should mesh together under one compliance officer who makes sure it’s all running as one system," Colitre says.

Hospital systems make good targets

HIM professionals should keep in mind that hospital systems traditionally are attractive targets for the government because they have the money to pay fines, Colitre adds.

Another fraud and abuse strategy is to know how peers are coding various procedures. The government often will target facilities where physician coding is outside the norm, Colitre says.

For example, if a particular facility has a greater-than-average number of codes for the more complex pneumonia cases, then the government might investigate to see if the facility is upcoding pneumonia cases.

Coders are responsible for making certain that a physician’s documentation adequately supports the diagnosis. If additional documentation is needed, the coder should send the physician a query form requesting more information.

However, coders need to be careful that they do not lead physicians to a coding answer, because doctors might just write down whatever the coder suggests, Scott adds.

For example, there’s often a problem deciding whether a code should be for septicemia or urinary tract infection. Clinically, the two are similar, although septicemia is more severe, and this code results in higher reimbursement from Medicare.

"The Office of Inspector General has found that some hospitals were overcoding septicemia when there wasn’t enough documentation to show it was that," Scott says. "So hospital coders are looking at these charts and thinking it could be septicemia, but it might not be. They need clear documentation from the physician that it is septicemia."

Coders need to be certain the physician’s documentation, blood culture findings, and clinical findings clearly indicate a septicemia diagnosis before it can be coded that way, Scott adds.

HIM departments that conduct regular audits of charts and coding will catch coding mistakes or physician trends that result in higher-than-typical charges.

"If an HIM auditor sees that one physician is always using a particular drug while peers are not, this should be called to someone’s attention," Colitre says. "HIM people can work with their compliance officers to [engage in] ongoing monitoring and to put systems into place that will assist individual departments to monitor properly."

Currently, an area that is receiving a lot of fraud and abuse attention is coding of patient services in connection with clinical research trials, Colitre says.

Typically, patients who are also research subjects receive free medications during a clinical drug trial, and the drugs usually are provided by the sponsor of the trial. But there are cases when the patients have side effects that require additional medication such as an anti-nausea agent, Colitre explains.

"You have to be very careful that if these drugs are being provided by the sponsors that you are not turning around and billing for them," he says. "It’s very critical that those charges are pulled out."

HIM professionals need to watch for those types of charges and should be aware of cases involved in clinical research so they can be sure there is no improper billing, Colitre adds. "Those people should be identified in information systems, and their trial research items should be clearly identified, accounted for, and not charged to the payer."