Pressure to upcode...

[notinkansas]

I'm currently working for a large private practice, not affiliated with any hospital. There is major pressure to upcode coming from management. Some of the midlevels in the practice code all of their visits as level 5, largely because management makes statements such as "all of our patients are sick enough to be level 5". I've been called out for being an outlier and having "too many" lower codes.

I can't find confirmation of this, but am I correct in assuming that each physician would be held responsible individually for his or her own coding in the event of an audit? Meaning "my boss made me do it" would not be a defense, right?

It's getting to the point where I'm starting to poke around for other employment opportunities.

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[gutonc]

I'm currently working for a large private practice, not affiliated with any hospital. There is major pressure to upcode coming from management. Some of the midlevels in the practice code all of their visits as level 5, largely because management makes statements such as "all of our patients are sick enough to be level 5". I've been called out for being an outlier and having "too many" lower codes.

I can't find confirmation of this, but am I correct in assuming that each physician would be held responsible individually for his or her own coding in the event of an audit? Meaning "my boss made me do it" would not be a defense, right?

It's getting to the point where I'm starting to poke around for other employment opportunities.

This is correct. While your employer would also be on the hook to pay a fine if you're audited and found to be in violation, you would as well.

Your only real chance to avoid it would be written proof that your employer was pressuring you to do this. Not just an email saying "Mr. Jones on Date X should have been coded Level 5 because of X, Y and Z", but an email saying "you need to be coding your patients higher".

 

[nlax30]

Whistle blower....... *cough cough*

 

[chessknt]

True level 5 visits should make up a minority of your coding. My memory serves that only about 10% of visits are coded this way from some cms stats I read. If all patients are being coded as 5 without any medical necessity (and no someone having chronic problems presenting for a knee sprain doesn't mean you can code as a 5 even if you get all the documentation right) you could report this to cms and get a slice of whatever they recoup. I'd strongly recommend you to code at the level supported by your documentation and medical necessity.

 

[cbrons]

Some of the midlevels in the practice code all of their visits as level 5

How is this not medicare fraud?

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[gutonc]

How is this not medicare fraud?

It is. They just haven't been audited/caught yet.

 

[gutonc]

True level 5 visits should make up a minority of your coding. My memory serves that only about 10% of visits are coded this way from some cms stats I read.

This is totally specialty and practice dependent. But yes, in general, the bulk of your return visits should be Level 3/4. It's pretty easy for me (an oncologist) to bill a level 5 on a f/u though...anybody getting chemo is at least a Level 4 and anything other than cancer/chemo, fatigue and CINV will get an easy level 5.

If you're in primary care (or anything actually) and just following up on things, no matter how many issues are addressed, without changing anything (BP at goal, continue losartan; A1c <7, continue metformin; HLD w/ LDL <80, continue atorvastatin; A fib on coumadin, followed by AC clinic), that's a level 3 (borderline 4) unless you can bill on time (totally not worth it for the most part).

 

[VA Hopeful Dr]

This is totally specialty and practice dependent. But yes, in general, the bulk of your return visits should be Level 3/4. It's pretty easy for me (an oncologist) to bill a level 5 on a f/u though...anybody getting chemo is at least a Level 4 and anything other than cancer/chemo, fatigue and CINV will get an easy level 5.

If you're in primary care (or anything actually) and just following up on things, no matter how many issues are addressed, without changing anything (BP at goal, continue losartan; A1c <7, continue metformin; HLD w/ LDL <80, continue atorvastatin; A fib on coumadin, followed by AC clinic), that's a level 3 (borderline 4) unless you can bill on time (totally not worth it for the most part).

That primary care scenario is an easy level 4. That said, in primary care you really shouldn't be billing very many level 5s. If you get above about 15% you're just begging for an audit. That said, you should have over 80% level 4 unless you just have the healthiest patients in history.

 

[Elixir6]

This is totally specialty and practice dependent. But yes, in general, the bulk of your return visits should be Level 3/4. It's pretty easy for me (an oncologist) to bill a level 5 on a f/u though...anybody getting chemo is at least a Level 4 and anything other than cancer/chemo, fatigue and CINV will get an easy level 5.

If you're in primary care (or anything actually) and just following up on things, no matter how many issues are addressed, without changing anything (BP at goal, continue losartan; A1c <7, continue metformin; HLD w/ LDL <80, continue atorvastatin; A fib on coumadin, followed by AC clinic), that's a level 3 (borderline 4) unless you can bill on time (totally not worth it for the most part).

All the garbage ICD 10 codes like "W61.02XD Being struck by a parrot, subsequent encounter" yet there is no specific code for chemotherapy induced nausea and vomiting. WTF! Like seriously, WTF!!!

We are told to bill everything at least E3 because of the nature of our IM practice involves a lot of people coming for IM consultations from far away.

 

[gutonc]

All the garbage ICD 10 codes like "W61.02XD Being struck by a parrot, subsequent encounter" yet there is no specific code for chemotherapy induced nausea and vomiting. WTF! Like seriously, WTF!!!

R11.2; T45.1

 

[drfunktacular]

unless you can bill on time (totally not worth it for the most part).

As a rheumatologist I do bill level 4/5 on time with some regularity... primarily for fibromyalgia patients who are (objectively) quite healthy, but it takes an hour+ for me to explain that to them...

 

[gutonc]

As a rheumatologist I do bill level 4/5 on time with some regularity... primarily for fibromyalgia patients who are (objectively) quite healthy, but it takes an hour+ for me to explain that to them...

I meant for primary care. I bill on time regularly too, usually when I have to go over new imaging or pathology results and spend 45 minutes instead of the usual 10 for just one issue.

Also, I can make more seeing 5 99213s in an hour than one 99215 in the same period of time.

 

[group_theory]

As a rheumatologist I do bill level 4/5 on time with some regularity... primarily for fibromyalgia patients who are (objectively) quite healthy, but it takes an hour+ for me to explain that to them...

If I was an auditor, I would look the other way and allow you to bill 99205s and 99215s for fibromyalgia patients based on "mental" complexity


To the OP - be careful of upcoding. If there is an audit, the admins will throw you under the bus and blame you as a rogue employee. The institution may get in trouble, but you as the physician will also be in trouble too, responsible for fines, paybacks with interests, and potential prison term. Under the federal false claims act, it provides for triple damages - so if you fraudulently bill for $1 million, you could owe $3 million. You can also face sanctions from the state medical board, and be barred from participating in Medicare/Medicaid in the future.

Check out these links. Hopefully your name won't be feature in a newspaper in the future

http://www.beckershospitalreview.co...1-5m-medicare-fraud-scheme-loses-license.html

http://archive.independentmail.com/...72-c0fb-4780-e053-0100007fb2aa-376464281.html

http://www.medpagetoday.com/practicemanagement/reimbursement/51914

http://www.post-gazette.com/busines...for-false-billing-claims/stories/201607270198

 

[drfunktacular]

If there is an audit, the admins will throw you under the bus and blame you as a rogue employee

This

 

[Raryn]

All the garbage ICD 10 codes like "W61.02XD Being struck by a parrot, subsequent encounter" yet there is no specific code for chemotherapy induced nausea and vomiting. WTF! Like seriously, WTF!!!

We are told to bill everything at least E3 because of the nature of our IM practice involves a lot of people coming for IM consultations from far away.

There's no physician visit period that can't be billed at least a level 3.

Look at the requirements sometime. You could have a low complexity follow up visit with a 1 element HPI, a "problem specific" ROS, absolutely no family/social history, and no exam and it meets technical criteria for a level 3.

For a consult, you need to examine 5 systems to get to level 3, but vitals counts as one and you can get four more just laying eyes on the patient, much less touching them. The other requirements for a level 3 consult are equally simple (4 element HPI, 2 system ROS, either family or social history).

 

[notinkansas]

If I was an auditor, I would look the other way and allow you to bill 99205s and 99215s for fibromyalgia patients based on "mental" complexity


To the OP - be careful of upcoding. If there is an audit, the admins will throw you under the bus and blame you as a rogue employee. The institution may get in trouble, but you as the physician will also be in trouble too, responsible for fines, paybacks with interests, and potential prison term. Under the federal false claims act, it provides for triple damages - so if you fraudulently bill for $1 million, you could owe $3 million. You can also face sanctions from the state medical board, and be barred from participating in Medicare/Medicaid in the future.

Check out these links. Hopefully your name won't be feature in a newspaper in the future

http://www.beckershospitalreview.co...1-5m-medicare-fraud-scheme-loses-license.html

http://archive.independentmail.com/...72-c0fb-4780-e053-0100007fb2aa-376464281.html

http://www.medpagetoday.com/practicemanagement/reimbursement/51914

http://www.post-gazette.com/busines...for-false-billing-claims/stories/201607270198

That's exactly what I'm concerned about. I know that if there is an audit the institution won't back me. On a periodic basis the office administration takes me aside and suggests that my percentage of level 5 visits is lower than everybody else's. Sometimes they even have a chart review. When they go through the chart review and show me examples of visits I coded as level 4 that they want me to change to 5, I point out these visits don't meet the criteria for level 5. So far, I've been able to get administration to back down. But I suspect many of my colleagues are upcoding.

 

[PlutoBoy]

That's exactly what I'm concerned about. I know that if there is an audit the institution won't back me. On a periodic basis the office administration takes me aside and suggests that my percentage of level 5 visits is lower than everybody else's. Sometimes they even have a chart review. When they go through the chart review and show me examples of visits I coded as level 4 that they want me to change to 5, I point out these visits don't meet the criteria for level 5. So far, I've been able to get administration to back down. But I suspect many of my colleagues are upcoding.

Don't upcode. This isn't up for discussion.

 

[pulmoblast]

Anonymous whistle blowers get financially rewarded too...


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[gutonc]

Anonymous whistle blowers get financially rewarded too...

Which is money you can use to offset the fine you get for upcoding.

 

[rokshana]

That's exactly what I'm concerned about. I know that if there is an audit the institution won't back me. On a periodic basis the office administration takes me aside and suggests that my percentage of level 5 visits is lower than everybody else's. Sometimes they even have a chart review. When they go through the chart review and show me examples of visits I coded as level 4 that they want me to change to 5, I point out these visits don't meet the criteria for level 5. So far, I've been able to get administration to back down. But I suspect many of my colleagues are upcoding.

if they show you that your level 4 can be justified as a 5 then change the coding...but if, as you have demonstrated, the note doesn't support a higher code...refuse...they will let it go (that does put them at risk, but you are at far more risk if you upcode without the documentation).

 

[notinkansas]

if they show you that your level 4 can be justified as a 5 then change the coding...but if, as you have demonstrated, the note doesn't support a higher code...refuse...they will let it go (that does put them at risk, but you are at far more risk if you upcode without the documentation).

I have been refusing. But it's becoming apparent that management has a problem with me refusing. I'm about to start looking for another job.

 

[pulmoblast]

Blow...the...whistle


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[gutonc]

I have been refusing. But it's becoming apparent that management has a problem with me refusing. I'm about to start looking for another job.

Blow...the...whistle

You definitely need to find another job. That's a no-brainer.

I'm not going to argue for or against blowing the whistle. But if you do, make sure that your ducks are lined up in a nice little row with bows on top before you do. Your documentation needs to support all of your coding. You need to have offline (and cached elsewhere) copies of any communication about your coding, or the coding practices of this place in general. Your case needs to be airtight, because, if they go down, they're going to try to bring you with them. You need to protect yourself.