Lately, OIG is reminding us we can’t seem to comply in ICD-9. I suggest that whatever happens by this time next year, don’t blame ICD-10. Coding is complicated with tons of rules and regulations. And yes, as soon as one learns something new the regulations change and even newer codes, modifiers, documentation, and incantitations are required. It’s been this way for years; and for years there has been noncompliance regardless of the code version. Not news you say? Where am I going with this? I just read another OIG audit report on yet another large provider. It makes me sad to learn they will have to pay back upwards of 1.6 million dollars in over payments for both inpatient and outpatient coding and billing issues. According to OIG, “The errors occurred primarily because they did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas.”
Hope is Not a Strategy
As Rick Page said in his bestselling book of the same title, hope is not a strategy. Cognizance, oversight, and strategic planning are required. In health care, there is a lot of strategic planning. Many focus on ways to finance the new wing, enlarge the ED, purchase physician practices, or build a new home for the latest technological miracle to provide the highest quality care. And it takes effort to please patients, remodel the entrance area or provide valet parking so a hospital, clinic or large practice resembles a soothing spa or attractive hotel. This is the exciting part of strategic planning. But why isn’t as much energy devoted to the often overlooked areas of coding and billing?
Administrators, CEOs, CFO, Boards, Medical Directors, and star physicians are remembered for the grand strokes – it’s necessary and uniquely human. But they are also remembered when a national news station reports that an independent 91-year-old female fell at home, fracturing her hip and sternum. She was taken to the hospital and as she and her family believed, admitted as an inpatient. Her fractures were treated, and she was released a few days later. All was fine until she got the bill for the $17,000.00 co-pay for services not covered by Medicare. Apparently, she had been placed on Observation Services which was not understood by her family. They approached their elected representative who was as stunned as the beneficiary.
I was surprised by the news coverage, and while I know the lay community has little knowledge of the burden of healthcare regulations, I predict there will be more of these stories on air going forward. Like it or not, health care is in the national spotlight and it’s not all flattering. It is important not to lose sight of the fundamentals. Know your vulnerabilities and pay attention. Audit, review, educate, communicate, research new coding tools, seek help from experts, and make coding and billing compliance as important as the new grand piano in the remodeled lobby. Your patients will thank you for it.
Barbara Aubry is a Regulatory Analyst for 3M Health Information Systems.