ROS frustrations

[EskimoFriend13]

Hey guys. I would appreciate some advice on this.
Since I am new to the game, I've been making an effort to do thorough review of systems so that my charts will satisfy requirements for the highest level of billing. I've been trying to do that on most of my patients until I get a better feel for who qualifies for the various levels. I have a macro built in for the things I ask, so it's easy enough to chart. My problem is that I'm not quite sure how to handle it when so many patients seem to be pan-positive. For instance, any time I ask about chest pain and the patients states they have it, I then have to go down a new line of questioning because I don't want to miss anything and then I document accordingly. But I get these people coming in for really minor complaints who will then endorse all of these potentially dangerous symptoms that they failed to mention previously when I asked why they came in. I had to stop using headache as one of my common questions because it turns out that everyone has a headache when they come to the ED. This happens ALL the time! How do you guys handle this?

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[emergentmd]

Pts 99% of the times comes with one complaint. I ask about that 1 complaint and a few associated questions. I NEVER do a full review of system. EM Docs can and should not do full review of systems.

How do I document? Everything I did not ask and they did not volunteer is NEGATIVE.

Sorry, I am in a busy ED. I have 5 Min Max with the pt, and hopefully no more than 2 min on initial hx/exam. Can't go through a full ROS, document everything positive, and then have to explain/work up every complaint.

Even if they give me a second complaint, I tend to ignore and not document it unless the pt is legit. These pts that gives me 5 complaints, gets the door after a quick workup.

 

[southerndoc]

How do I document? Everything I did not ask and they did not volunteer is NEGATIVE.

Let's hope CMS doesn't send a secret shopper to visit you. They've been sending them lately. Those that check "all other systems reviewed and are otherwise negative" will be in a huge amount of trouble if a secret shopper isn't asked all the questions.

 

[emergentmd]

I get where you are coming from. With all the metrics, PQRS, CMS guidelines, order sets, protocols, alerts, time metrics I can barely even think about the pt.

On top of that, you want me to do a full ROS, take all complaints seriously, address each complaint, address all of their pain, and then document using an archaic system?

Good luck to anyone who can do this.

I will roll the dice like 90% of the docs who do focus exams/history and give the pts good care.

 

[southerndoc]

I get where you are coming from. With all the metrics, PQRS, CMS guidelines, order sets, protocols, alerts, time metrics I can barely even think about the pt.

On top of that, you want me to do a full ROS, take all complaints seriously, address each complaint, address all of their pain, and then document using an archaic system?

Good luck to anyone who can do this.

I will roll the dice like 90% of the docs who do focus exams/history and give the pts good care.

I agree with you. What is being asked of emergency physicians to do is impossible. You can't have every emergency physician in the country be perfect.

 

[Doctor Bob]

I don't feel bad charting level 2's and 3's when that's the level of care I give. Every patient can't be a level 5.
Someone has to hold up the middle of the bell curve.

 

[gman33]

Charting and providing care are different things.
You are not a scribe. Your chart should reflect how you synthesize the data that you collect.

Never ask a patient a question if you don't want to know the answer.
There for ankle pain. Don't ask about HA or CP. (unless you think it's relevant).

If they give you extra data that you don't think is important, either ignore it, or write in your chart why you think it is not relevant to your medical evaluation.

Everyone goes through this as part of their training.
They told me they have a HA, do I now need to LP them because they might have a SAH? etc...

In the early part of your training, it's probably a good thing to think about all these complaints.
It will make you slow, but it will help your education.
Later on you will get a better sense of what can be ignored.

For billing it is much more complicated.
Not everyone needs a level 5 chart, but I'd try to document to the highest level that is appropriate.

 

[swamprat]

I have a macro that I use for every patient. Abdominal pain patients will get a pretty thorough and quick ros, the headache patient not so much. I think it's pretty dumb but that's how we have to bill so oh well..The attendings I wor with like all charts written to a level 5. They end up being downgraded once you calculate all the other charges such as nursing documentation, lack of procedures, labs etc.

 

[gro2001]

Hey guys. I would appreciate some advice on this.
Since I am new to the game, I've been making an effort to do thorough review of systems so that my charts will satisfy requirements for the highest level of billing. I've been trying to do that on most of my patients until I get a better feel for who qualifies for the various levels. I have a macro built in for the things I ask, so it's easy enough to chart. My problem is that I'm not quite sure how to handle it when so many patients seem to be pan-positive. For instance, any time I ask about chest pain and the patients states they have it, I then have to go down a new line of questioning because I don't want to miss anything and then I document accordingly. But I get these people coming in for really minor complaints who will then endorse all of these potentially dangerous symptoms that they failed to mention previously when I asked why they came in. I had to stop using headache as one of my common questions because it turns out that everyone has a headache when they come to the ED. This happens ALL the time! How do you guys handle this?

There are some jedi mind tricks that you will learn through residency that will make some of this easier.

Most importantly, there are different ways to ask your questions. Things that I actually want to know the answer to, I ask as a separate question and wait for an answer, sometimes double check. For example, reviewing for the complaint of "headache"

"Have you also had any fever? Are you sure?
Any trauma? No?
How about any change in you vision? Like double vision?"
etc.

But when I want to do a 'screening' ROS for things I don't actually expect to be positive, it sounds more like:

"Ok, I think I get the picture. Is anything else really bothering you? Anything stand out?"
"No... I don't think so..."
"Ok, good. So no vomiting, diarrhea, rashes, fever, foreign travel, chest pain, difficulty breathing, trouble walking or urinating or things like that?"
"Umm... no"

It's easy to make it sound like you are just going through the motions, and that's where your tone and body language will play a role. I find that with this method I decrease the amount of 'pan positive' ROS to the minimum and still occasionally pick up a relevant detail. Also it allows me to chart with peace of mind

 

[TooMuchResearch]

"And anything else going on today that is new AND out of the ordinary for you: (insert rapid fire ROS here)?"

 

[Janders]

Agree with above. Some complaints will never be a 5 and don't need a real ROS aside from what you get in your HPI.

Many patients I will ask a pertinent ROS (have you been sick lately? fevers or anything? Any pain in the chest, trouble breathing, belly pains?). This goes with a lot of elderly / vague patients. Between those questions and your HPI, you likely have a 10 point ROS without cheating.

If you want to make it really snappy, you can ask "any pain, bleeding, or fevers?". If they say NO, you can expand that do a negative 10pt ROS (No headache, no sore throat, no eye pain, no chest pain, no belly pain, no joint pain, no hematemesis/bloody stool, no hemoptysis, No fever)...

 

[EskimoFriend13]

Thanks for the input everyone.
I've kind of been doing 2 ROS's like some of you described. My initial one with all the related questions as part of my HPI and then a generic one I run through during my PE for billing requirements.
I wish I could just ask "anything else?" for the latter but I worry it will come back to bite me.
I will definitely try out some of the phrasing you guys have suggested. That'll make things a lot easier. Thanks for the tips!

 

[Psai]

The amount of nonsense that you guys put up with is astounding

 

[Old_Mil]

What gro2001 said.

 

[filhodeinferno]

"And anything else going on today that is new AND out of the ordinary for you: (insert rapid fire ROS here)?"

Yep, rapid fire for the win. Otherwise every damn patient would get full CP and abdominal pain workup. Seriously, when was the last time you asked the patient if they had shortness of breath and they said no?

 

[The White Coat Investor]

Never ask about a headache in your ROS. All ED patients have a headache. Seriously. That question is NEVER answered no.

I love the "Any pain or bleeding?" question. It gets you
Neuro - Headache
Cardiac - Chest pain
Eyes - Eye pain
ENT - Sore throat
GI - Abd pain
GU - Flank pain, pelvic pain, penile pain
MS - Joint pain

Pulmonary- Hemoptysis
GI- Hematemesis/hematochezia
ENT- Epistaxis
GU- Vag bleed
Heme- Easy bruising or bleeding
and maybe even Psych- Cutting behavior

That's 9 right there! I also like asking my questions in such a way that they are more likely to be answered no.

For instance, "Any pain, bleeding, fever, or desire to kill someone else?" Or "Any pain, bleeding, fever, or penile discharge?" "Any pain, bleeding, fever, or STD symptoms?"

You would think more people would learn this art in residency, but I've seen way too many attendings with the computer in front of them asking one question at a time, 3 questions per organ system, 12 organ systems. Click, click, click, click. Ugh. If that's what you want your practice to be.....

 

[The White Coat Investor]

We should start a list of stuff NOT to ask about:

Headache
Rash
Chills
Dizziness
Sweatiness
Fatigue

for starters. Never ask about any symptom that as a chief complaint you hate working up!

 

[gro2001]

Never ask about a headache in your ROS. All ED patients have a headache. Seriously. That question is NEVER answered no.

I love the "Any pain or bleeding?" question. It gets you
Neuro - Headache
Cardiac - Chest pain
Eyes - Eye pain
ENT - Sore throat
GI - Abd pain
GU - Flank pain, pelvic pain, penile pain
MS - Joint pain

Pulmonary- Hemoptysis
GI- Hematemesis/hematochezia
ENT- Epistaxis
GU- Vag bleed
Heme- Easy bruising or bleeding
and maybe even Psych- Cutting behavior

That's 9 right there! I also like asking my questions in such a way that they are more likely to be answered no.

For instance, "Any pain, bleeding, fever, or desire to kill someone else?" Or "Any pain, bleeding, fever, or penile discharge?" "Any pain, bleeding, fever, or STD symptoms?"

You would think more people would learn this art in residency, but I've seen way too many attendings with the computer in front of them asking one question at a time, 3 questions per organ system, 12 organ systems. Click, click, click, click. Ugh. If that's what you want your practice to be.....

Hehehe... this gives me the idea of pairing questions I want a negative answer to with questions they are likely to answer no to...

"Any chest pain or penile discharge?"
"Any headache or vaginal itching?"
"Any belly pain or scrotal deformity?"

 

[Janders]

Headache
Rash
Chills
Dizziness
Sweatiness
Fatigue

Good list.
EVERYONE has a headache, including me. Not asking unless it is pertinent.
EVERYONE feels dizzy / lightheaded / weak / fatigued / tired, including me. Again, not asking unless it is pertinent (vertigo, anemia, etc).
EVERYONE has chills. It hilarious. Ankle sprain? "yea doc I had chills this AM". Heat Stroke? "yeah doc, the chills all night!". Manic psychosis + K2? "The chills are speaking to me, and they say I should kill you!". Not asking!

Now THAT said, I love discovering a truly diaphoretic patient. You can't fake the sweats. Diaphoresis = badness. Its going to be an acute MI, ischemic gut, aortic dissection, bacteremia... SOMETHING. So diaphoresis is worth a lot in my opinion. But if you just ask about "sweats" everyone will say yes. I feel the same way about RIGORS. If you get people rigor'ing in front of you, or truly describing rigors ("I was about to shake out of the bed, doc!"), this has a very strong positive predictive factor for bacteremia. VERY strong. The trick is to tease our rigors versus vague chills which apparently plague 99% of ED patients.

So, I don't want to dissuade any young ones from taking a complete history... there is gold in them there hills! Just avoid the fools' gold...

 

[Vandalia]

I blame television. Certain shows have led patients to believe that the slightest symptom can be the key to discovering their incredibly rare medical disorder. So you have a rash between your toes and had a 2 minute hiccoughing spell three days ago? That must mean you have podocytoma!

Even if you exclude the patients with psychological issues or those looking for secondary gain, many very reasonably believe every tiny clue is essential to a correct diagnosis. In theory that should be a good thing since it should result in a very accurate history. In reality it just means more hay in which to try and find the proverbial needle.

 

[deleted547339]

We should start a list of stuff NOT to ask about:

Headache
Rash
Chills
Dizziness
Sweatiness
Fatigue

for starters. Never ask about any symptom that as a chief complaint you hate working up!

Chills. Everyone has chills. Every single time a med student tells me the patient has chills, I tell them to stop and never ask that question again. And "I stay cold" seems to be a favorite among my patient population. I also demand a number on a thermometer before I will concede that a patient had a fever.

On a related note, it only took a couple pelvic exams in my headache, chest pain, <insert other non-GU complaint here> patients before I stopped asking about discharge.

To all the med studs and 'terns out there, another important trick (one I think I learned on SDN) is to end a series with emphasis and on something they definitely don't have. Do you have any headache, vision changes, cp, sob, abd pn, blood in your stool, rash, SEIZURES?

I tend to fall into the camp of directed questioning followed by "another other problems you didn't mention?" I can sleep at night documenting a 10pt ROS with the pertinent questions plus that catch-all.

 

[Apollyon]

To all the med studs and 'terns out there, another important trick (one I think I learned on SDN) is to end a series with emphasis and on something they definitely don't have. Do you have any headache, vision changes, cp, sob, abd pn, blood in your stool, rash, SEIZURES?

That was @The White Coat Investor.

 

[deleted547339]

That was @The White Coat Investor.

Sounds about right.

 

[LaBusqueda]

The whole ROS thing is a simple silly hoop to try and nick as many charts from max codes as possible.

In our training we learn exactly what ROS questions MUST be asked per every CC to get to the emergent risk associated! Period!
The remainder is simply a juggling monkey show to satisfy cod ring requirements that pretty much require fraud on a daily basis.
A always ask a very good general assortment of questions in rapid fire that will satisfy my tag line of "remainder of x systems reviewed with the patient and found to be negative unless mentioned above in the HPI"
Tens of thousands of charts this exact way and no problems ever.
Do not make the mistake of selling yourself and our specialty short on billing even with seemingly little things.
Did you think even for a micro second on a seemingly low code chart was there a cellulitis, deep infection, compartment syndrome, NV compromise??
Did you? If so, that is a complicated bit of MDM that WE take for granted but gives that chart a legit up code!!
Again disagree if you want, I was trained this way and my charts reflect what I think and I bill for it!

ROS is a joke, MDM is real. And also get all those hoop jumping HX parts

 

[EMIM2011]

I ask "anything else going on anywhere?" and motion with my hands from top to bottom....that catches all organ systems (except psych maybe). Who says that the ROS has to be a specific verbal prompting / yes/no game anyways....

 

[filhodeinferno]

We should start a list of stuff NOT to ask about:

Headache
Rash
Chills
Dizziness
Sweatiness
Fatigue

for starters. Never ask about any symptom that as a chief complaint you hate working up!

My, my two worst are dizziness and blurry vision. Don't ask, don't tell...

 

[emergentmd]

What we are taught in Medical school and to lesser extent residency from most important to least (and how much time you should put into it)

1. History
2. Physical
3. Labs

What it is in real life EM

1. Labs/testing
.
.
.
5. Exam
.
.
.
100 - History

I am deal serious about this.

 

[coachB]

.

 

[southerndoc]

I ask "anything else going on anywhere?" and motion with my hands from top to bottom....that catches all organ systems (except psych maybe). Who says that the ROS has to be a specific verbal prompting / yes/no game anyways....

For an E&M level 5 coding, CMS dictates that you must specifically ask pertinent negatives and positives related to the organ system as the chief complaint, and you are permitted to document "all other systems reviewed and negative" for non-related organ systems. However, you must ask at least one ROS question in each of the 10 organs systems.

Simply asking "anything else going on?" may save you time, but you're playing with fire if you ever get audited. Not likely to happen (yet), but physicians have gone to jail for falsely documenting and filing with CMS. CMS is serious about recovering payments and reducing future payments.

 

[LaBusqueda]

Would love to hear from someone who has been audited. How would they prove anything?
There is no way a pt can be expected to regurgitate if a physician went through specific symptoms. It will fall to their word, likely after pain meds and acute pain and stress against the medical record.
I just can't see how it would hold up assuming you asked pertinent ROS in the HPI

 

[Vandalia]

Simple. Have a patient record the physician asking about the history during the visit

I have heard RUMORS that several insurance companies have told their employees, if you ever have to go to the ED, be sure to record the encounter, and we will pay you $XXX extra for the information.

 

[deleted547339]

Simple. Have a patient record the physician asking about the history during the visit

I have heard RUMORS that several insurance companies have told their employees, if you ever have to go to the ED, be sure to record the encounter, and we will pay you $XXX extra for the information.

Isn't that illegal?

 

[erdoc00]

I love that this is something we're even discussing. Maybe it's time for doctors to take back control of medicine and stop the ridiculousness. We can only "overlook" so many "minor inconveniences" before we're entrenched in a situation where 10% of what we do is actually medicine and the rest is unrelated nonsense, much of which actually negatively impacts care.

 

[southerndoc]

Isn't that illegal?

Depends on the state. In Georgia, only one party has to know about the recording.

CMS uses secret shoppers.

I've known of physicians who have been audited by CMS, but it was mainly auditing medical complexity/decision making to support an E&M 5.

 

[LaBusqueda]

Secret shoppers. That's what we have come to. Can not wait to be out of medicine, just need the lottery investing to pay off

 

[DeadCactus]

We should start a list of stuff NOT to ask about:

Headache
Rash
Chills
Dizziness
Sweatiness
Fatigue

for starters. Never ask about any symptom that as a chief complaint you hate working up!

I'll add blurry vision to the list. I've never met a patient without chills and blurry vision...

 

[gro2001]

You can increase the specificity of some of these by adding an adjective. I usually ask about any "shaking chills".
Also you can just add unusual to increase your yield. "Any UNUSUAL headaches, rashes, sweatiness, etc over the past week?"

 

[deleted77919]

…

 

[EskimoFriend13]

Update: I've been trying out a few of the suggestions above. It's definitely making things much easier! Thanks guys

 

[sum dude]

Hey guys. I would appreciate some advice on this.
Since I am new to the game, I've been making an effort to do thorough review of systems so that my charts will satisfy requirements for the highest level of billing. I've been trying to do that on most of my patients until I get a better feel for who qualifies for the various levels. I have a macro built in for the things I ask, so it's easy enough to chart. My problem is that I'm not quite sure how to handle it when so many patients seem to be pan-positive. For instance, any time I ask about chest pain and the patients states they have it, I then have to go down a new line of questioning because I don't want to miss anything and then I document accordingly. But I get these people coming in for really minor complaints who will then endorse all of these potentially dangerous symptoms that they failed to mention previously when I asked why they came in. I had to stop using headache as one of my common questions because it turns out that everyone has a headache when they come to the ED. This happens ALL the time! How do you guys handle this?

Ask a bunch at one time, add "or anything weird like that?" eg any CP, sob, bleeding, bloody stools, lightheadness, congestion, cough, fevers, abd pain, peeing yourself, or anything weird like that?

Ask at end "any other symptoms." If they say no, then you've fulfilled "all other ROS negative."

You're welcome--now good luck with the 5 million other documentation and order things your quality mgmt team will want you to "hit for metrics" which is infinitely more complicated than checking boxes. Trust me don't get caught up in the forest from trees..

 

[Daiphon]

I'd add one more thing (which may have already been said, so I apologize if it's redundant):

In regards to the ROS, and in addition to all the advice above, I also recommend reading the triage note and specifically negating any symptoms documented by the RN that the patient denies to you. Don't just rely on "all other systems have been reviewed & are noncontributory." You can get burned. Phosphorus-level scorched.

I usually add "triage note states X, but patient specifically denies X, Y, Z (with Y & Z being related synonymous symptoms) to me during evaluation."

-d

 

[Angry Birds]

Are you guys sure that you get burned for clicking all other systems negative? I feel like this would be a safer thing to do than putting in specific negative symptoms. Because in the former you can at least justify yourself more so than if you have specific symptoms listed which you didn't ask. Because from my standpoint the former is a judgement call by the physician that nothing else is going on.

 

[southerndoc]

Are you guys sure that you get burned for clicking all other systems negative? I feel like this would be a safer thing to do than putting in specific negative symptoms. Because in the former you can at least justify yourself more so than if you have specific symptoms listed which you didn't ask. Because from my standpoint the former is a judgement call by the physician that nothing else is going on.

No, it's not a judgment call. It's saying you reviewed "all other systems" and they were negative.

 

[Vandalia]

No, it's not a judgment call. It's saying you reviewed "all other systems" and they were negative.

Agree. It is pretty basic criminal law. If you say you "did X", and receive compensation for that false claim, it is a crime. If you submit an enhanced claim to a government insurance program based on "reviewing x" when you actually did not, then you have committed health care fraud. Now granted, I doubt the entire wrath of the Justice department is going to come down on you for that alone, but if you get caught up into something else that is investigated it is possible. For example, if a spine surgeon is investigated for massive health care fraud, and in tracking it all down they come across ED records that are questionable, it is possible you can get sucked into that investigation.

There can be extremely fine line between maximizing reimbursement through proper coding and stepping over the line into fraud. It is a decision you have to make for yourself, but I am not going to federal prison for 20 years for fraudulently bumping a level 4 to a level 5. Now someone will probably say the government has intimidated me into saving them money. Well, yeah.

 

[Birdstrike]

Hey guys. I would appreciate some advice on this.
Since I am new to the game, I've been making an effort to do thorough review of systems so that my charts will satisfy requirements for the highest level of billing. I've been trying to do that on most of my patients until I get a better feel for who qualifies for the various levels. I have a macro built in for the things I ask, so it's easy enough to chart. My problem is that I'm not quite sure how to handle it when so many patients seem to be pan-positive. For instance, any time I ask about chest pain and the patients states they have it, I then have to go down a new line of questioning because I don't want to miss anything and then I document accordingly. But I get these people coming in for really minor complaints who will then endorse all of these potentially dangerous symptoms that they failed to mention previously when I asked why they came in. I had to stop using headache as one of my common questions because it turns out that everyone has a headache when they come to the ED. This happens ALL the time! How do you guys handle this?

You're still actually asking 10 system reviews of systems on ER patients?

Dude. Stop. Take the training wheels off. Don't. Just don't.

Have you seen a single ER attending ask a gunshot patient if they "have vag-itch, night sweats, hearing loss, night sweats or breast lumps" or an MI patient, "By chance do you ever get the sensation of tenesma when you're taking a grump?"

Nope. You haven't.

S T O P

 

[Birdstrike]

Agree. It is pretty basic criminal law. If you say you "did X", and receive compensation for that false claim, it is a crime. If you submit an enhanced claim to a government insurance program based on "reviewing x" when you actually did not, then you have committed health care fraud. Now granted, I doubt the entire wrath of the Justice department is going to come down on you for that alone, but if you get caught up into something else that is investigated it is possible. For example, if a spine surgeon is investigated for massive health care fraud, and in tracking it all down they come across ED records that are questionable, it is possible you can get sucked into that investigation.

There can be extremely fine line between maximizing reimbursement through proper coding and stepping over the line into fraud. It is a decision you have to make for yourself, but I am not going to federal prison for 20 years for fraudulently bumping a level 4 to a level 5. Now someone will probably say the government has intimidated me into saving them money. Well, yeah.

I don't condone billing fraud, but this "going to federal prison for 20 years for fraudulently bumping a level 4 to a level 5" does not happen. The people that go to jail for healthcare fraud are the ones billing for surgeries they didn't do, on patients that are dead, charging 50 million per year to medicare when the avg for their specialty is 1 million, people charging medicare for motorize scooters they never dispensed to patients and the like.

There is no jail time for bumping a level 4 to a 5. I'm not condoning it, but what they actually do with that is fine you. They do an audit. If they find you uploaded, lets say 30% of your charts from 4 to 5, then they hit you with a fine which is the difference between a level 4 and 5 for all your levels 5's for the past 6 months, year, or whatever, plus penalties. Still, this rarely happens, if you're even making a reasonable effort to code correctly and document supportively.

If you were taking sore throat patients and slapping bunches of procedures you didn't do, billing critical care on 100% of your patients or really egregious stuff like that, then you're beyond wrist-slap territory. These auditors get paid based the size of the fish they catch, much like the IRS. They're not likely to waste their time on a few bucks here and a few bucks there. They're looking for big time amounts of money. Tens to hundreds of thousands, minimum. Similarly, the IRS could give a ---- if you deducted a $50 receipt you shouldn't have. Failed to report $50,ooo? Okay. That might get their attention.

Be honest. Follow proper coding and billing. Do your documentation and you'll be fine. But don't freak out about this stuff. They have rapists and murderers that they need to prosecute and aren't going to waste court time on some guy who bumped a level 4 to a level five a couple of times, by accident. There are enough scumbags doing stuff so dirty and egregious you wouldn't even believe, and they're busy with that.

 

[Vandalia]

There is no jail time for bumping a level 4 to a 5. I'm not condoning it, but what they actually do with that is fine you. They do an audit. If they find you uploaded, lets say 30% of your charts from 4 to 5, then they hit you with a fine which is the difference between a level 4 and 5 for all your levels 5's for the past 6 months, year, or whatever, plus penalties. Still, this rarely happens, if you're even making a reasonable effort to code correctly and document supportively.

I think we are talking about different things probably because I was not completely clear in my last sentence.

Most coding discrepancies are in fact handled through audits and fines based on the contract as you point out. However, this presumes two things: The discrepancies are in a relatively small fraction of the total claims and there is no other underlying fraud. If a PCP codes every blood pressure check and common cold visit as a level 5, that will almost certainly be viewed and handled much differently than an audit that reveals that 13% of level 4's were coded too high and 11% were coded too low. Also, if there is misrepresentation in the medical record that is consistently being used to support the up-coding that is also usually viewed and handled differently.

 

[southerndoc]

There are a couple of ways CMS can audit you. CMS randomly audits 2% of all submitted claims. Additionally, if a nurse, coworker, etc. thinks you are upcoding, they can report you as a whistle blower and get paid some of the money CMS gets back.

Audits for upcoding are increasing because of EMR's. In this type of audit, they specifically target a hospital or health system and randomly review charts.

CMS Administrator Marilyn Tavenner said at the March meeting of the Federation of American Hospitals that her agency would undertake targeted audits focused on EHR-related upcoding. That was followed by a May 3 “listening session” hosted by the CMS and the Office for the National Coordinator of Health IT to discuss the increased billing that has occurred in some hospital codes.​

Birdstrike is right in that I do not believe a physician has gone to jail for upcoding, but that doesn't mean there won't be a first. Most of the time CMS will recover the money. Violation of the False Claims Act allows CMS to recover three times the money fraudulently paid as well as issue fines up to $11,000 per incident.