Watch for these red flags in compliance activities

Make sure coding, documentation are in order

When Jay Williams works with physician practices on compliance issues, he inevitably finds problems with coding and documentation.

"Every time we look at a physician group, we find problems with coding. And, as often as not, they are directly related to downcoding as well as upcoding," says Williams, principal of Arista Associates, a health care consulting firm in Northbrook, IL.

Physicians practices don’t deliberately upcode, he adds. In most cases, it’s due to a lack of education and training and the practice’s failure to hire people who understanding coding and can do a good job of coding properly.

In addition to helping you avoid penalties from the government, proper coding can have a positive effect on your bottom line.

"My experience over the past few years is that it’s very simple to find revenue on the downcoding side," Williams adds.

Documentation for coding is another item that has been a chronic problem for group practices, Williams adds. To ensure that you comply with government regulations, make sure that your charts are complete and that they support the coding for that patient. If you are coding appropriately, there must be enough information on the chart to support the coding.

"If a patient has a multisystemic illness, there’s nothing wrong with coding appropriately, but you’ve got to prove it," Williams says.

Proper documentation is essential for being in compliance with government regulations, he adds. "Realistically, the OIG’s concerns come from poor documentation and reporting than from any intent to defraud. However, an inad-vertent practice of upcoding could give the semblance of fraud, and that’s not a situation you want to be in."

One issue that Williams has found in many group practices is that supervising physicians fail to sign off on the chart notes of physician extenders. "I have found an unbelievable number of times it doesn’t happen."