PRESENTATION ON CODING COMPLIANCE ISSUES

1
PRESENTATION ONCODING COMPLIANCE ISSUES

• February 7, 2002
• Andrew Ruskin
• Vinson Elkins, L.L.P.
• Washington, D.C.

2
OIG Initiatives Involving Coding

• Hospitals
• Payments to acute care prospective payment system
  hospitals.
• Outpatient prospective payment system.
• Home Health Agencies
• Coding of home health resource groups.
• Physicians
• 1. Physician evaluation and management codes.

3
OIG Compliance Program Guidances

• Hospitals
• Cautions against
• Upcoding.
• Failing to maintain documentation supporting the
  claim.
• Failing to use the most recent coding manuals
  issued by the AMA and CMS.
• Billing for laboratory services that are either
  improperly coded or are coded by someone other
  than qualified personnel.

4
OIG Compliance Program Guidances (cont.)

• Nursing Homes
• Cautions against
• Providing misleading data on the Minimum Data Set
  (MDS) instrument.
• Failing to maintain sufficient documentation to
  support the diagnosis.

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OIG Compliance Program Guidances (cont.)

• Physician Practices
• Cautions against
• Failure to use proper modifiers.
• Clustering.
• Upcoding.
• Advises to conduct self-audits to determine if
  coding is being done accurately and in accordance
  with documentation.

6
OIG Compliance Program Guidances (cont.)

• Third Party Billing Companies
• Cautions against
• Percentage fee arrangements.
• Using faulty or outdated software.
• Assumption coding.

7
OIG Compliance Program Guidances (cont.)

• Third Party Billing Companies (cont.)
• Recommends that documentation include
• a. Reason for patient encounter.
• b. Appropriate history and evaluation.
• c. Documentation of all services.
• d. Documentation of reasons for the services.
• e. An ongoing assessment of the patients
  condition.
• f. Information on the patients progress and
  treatment outcome.

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OIG Compliance Program Guidances (cont.)

• g. Treatment plan.
• h. Plan of care, including services furnished by
  other practitioners.
• i. Changes in the treatment plan.
• j. Abnormal test results.
• Identification of relevant health risk factors.
• Compliance with EM coding documentation
  standards.
• Dates and authentications on medical records.
• n. Prescriptions.

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Self-Auditing for Coding Compliance

• Structure
• Sample size do you need a statistical sample?
• Size of team and its members do you include
  counsel? Outside consultants?
• Scope of audit how many criteria are you
  testing?

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Self-Auditing for Coding Compliance (cont.)

• Execution
• Modifications and expansion may be necessary.
• Discretion should be maintained.
• Follow-up
• Repayment.
• How much?
• To whom?
• Education of staff.

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Managing an OIG Audit

1. Know the law.
2. Know yourself.
3. Gather information from other organizations.
4. Negotiate scope and timing.
5. Manage your employees.
6. Appoint a liaison.
7. Seek to review the final determination.