Despite delay, correct coding remains critical
Despite delay, correct coding remains critical
One of the things that concerned many physicians about the proposed 1997 E/M guidelines was the fear that billers would be penalized for inadvertent coding mistakes due to unfamiliarity with these new and complex rules.
In her April 27 letter to the American Medical Association's April Chicago fly-in conference, HCFA administrator Nancy-Ann Min DeParle said, "I want to assure you that physicians will not be punished for honest mistakes and we will not make referrals to the Office of the Inspector General for occasional errors. We have to believe there is some level of fraudulent intent before we make any referrals."
DeParle also emphasized that "Medicare does not pay for medically unnecessary claims," and when it comes to having physicians properly document their claim submissions, "we still have much work to do."
According to the Office of Inspector General's just-released audit of Medicare's financial operations (see related story at right), physicians received 44% of the $23.1 billion in suspect Medicare payments made by HCFA in FY 1997. Of this, poor documentation accounted for 29% of improperly paid physician claims.
While HCFA says innocent coding errors will not be prosecuted and there must be evidence of intent to defraud before it will refer cases for criminal investigation, "actions are intended for physicians who act in 'deliberate ignorance' or with 'reckless disregard' of the truth or falsity of information, " DeParle also emphasized in her April 27 letter.
"Basically, the message I get is no matter whether you use the 1997 or 1995 E/M guidelines, HCFA is out there auditing, so you better make sure your documentation is in order," says Catherine Fischer, reimbursement policy advisor for Marshfield (WI) Clinic.
In reaction to the OIG's financial audit, HCFA plans to beef up both its pre-payment audits - where physicians must send in all back-up documentation before a claim is paid-and traditional post-payment audits in hopes of lowering the rate of inappropriate physician Medicare payments.
Looking for obvious patterns of suspect activity will be a key part of this enhanced policing of payments, notes Fischer. One seemingly simple but common thing auditors look for is a pattern of consistent charges for the same level of service by a physician, says Fischer.
"Like just about everyone else involved in the delivery of medical services, HCFA knows the level of medical services provided varies with each patient," notes Fischer. In turn, "when auditors notice a particular doc always checks off a four level of service, or even a two, this sets off an alarm that there may be overbilling occurrences."
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