Coding Abuse: Avoiding Enforcement Actions With Common Sense Protections

November 6, 2018 by Antonio Arias, MBA, CHBME

Topics: Practice Management, Medical Billing Company

Submitting “clean” claims is something we emphasize here on the blog all the time – mostly in the context of ensuring forms and fields are filled out clearly for processing. But there’s another factor that makes a claim “clean,” too: its legality.

Fraudulent claims are in the government’s crosshairs. The U.S. Department of Justice (DOJ) enforces the False Claims Act, Anti-Kickback Statute, and other laws by cracking down on coding abuse – taking aim at improperly used modifiers, overcharged services, unnecessary equipment, and so on.

That means that upcoding and downcoding can destroy your practice – and if your staff isn’t diligent about cross-checking code use, fraudulent activities on your team could pass undetected until it’s too late. Sniff out problematic coding practices on your team with these tips.


Check Your E/Ms

Modifier -25 reports a “significant, separately identifiable” evaluation and management (E/M) service performed by the same physician on the same day as a given procedure. Modifier -59 signifies that two procedures, rather than one, are billable.

Because they can be misused to get one E/M reimbursed for more than it’s worth, these modifiers pose widespread potential for abuse. The Office of Inspector General has long targeted the problem, yet many practices still attempt to defraud Medicare by using these codes improperly.

Getting caught costs a lot: In 2016 for example, Southeast Orthopedic Specialists will pay $4.488M to settle False Claims Act allegations related to submitting certain claims that used modifiers 25 and 59 inappropriately (among other allegations).

Modifiers always demand double-checking, but practice leaders should watch for a spike in providers’ use of these -25 and -59 in particular. If there’s any hint of improper use, administrators should immediately audit the situation before regulators do it for them.


Protect with Prevention

Short of an audit, how else should practices sniff out abuses?

Coding consultants (or even a medical billing firm) can review a statistically relevant sample of your claims if you fear any pervasive problems. In fact, working with a third-party medical billing service is one of the smartest ways to help ensure compliance, as many go out of their way to adhere to OIG recommendations on coding practices.

If you’re not ready to outsource, applying the same recommendations inside your own operations is a smart way to get more careful about coding. Consider creating and circulating standards of conduct and appointing an office czar who teammates can approach with concerns, questions, or “unclean” claim issues they spot in the course of their jobs.


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