"Upcoding" Fines and How to Avoid Them

Medicare Review Consultant provides an overview of the most common infractions.

By Kieren P. Knapp, DO, FACOFP dist.

Quite often, we hear of colleagues who have gotten into trouble with private insurers or Medicare intermediaries for billing issues. They may have paid back substantial amounts of money, and may even have been “fined” for these problems. This is not to be confused with outright fraud and abuse issue that are intentional and deliberate.

Until recently, billing was unfortunately learned by casual conversation or observation during postgraduate training. Rarely was there any formal training regarding the business side of medicine. Advice from the local physician “experts” ranged from underfilling everything to escape any scrutiny to billing to the maximum for everything and still push the limits for extras.

Probably the most common infractions or errors that I encounter as a Medicare Review Consultant are medical necessity or “upcoding” issues. Both are frequent patterns that are encountered without respect to age or residency/postgraduate training of the physician involved.

An example of a medical necessity issue that is commonly seen in non-Medicare/Medicaid reviews involves the use of an in-office laboratory. Serial testing of hyperlipidemia or hypercholesterolemia patients seems to be very prevalent in these cases. Most often, I encounter reviews involving monthly testing of cholesterol or LDL, along with either ALT or AST.

Sometimes, there has even been monthly testing with a complete lipid and liver profile being performed. Current guidelines for the treatment of hyperlipidemia or hypercholesterolemia do not list this practice as a necessary or even desirable. As such, this is an over utilization or medical necessity issue.

“Upcoding” becomes a bit more complex, but is often obvious to a reviewer. Not only can “upcoding” be seen with procedure codes, but with E/M codes as well. In fact, the latter is much more frequent. Even though this will probably be resolved with the eventual development of the E/M Worksheet and formula, that “cookbook” approach is not yet in effect.

What I most often encounter is a brief, problem-focused progress note (99212) with the entire list of current and chronic diagnoses listed as an impression and billing submitted for a complex, comprehensive visit (99215).

There are key points to remember in this scenario. First, if the progress notes do not say something, it does not exist. For example, when the progress notes contain a history of “recheck: and a physical addressing only b/p, heart, and lungs, a code for a comprehensive visit (99215) cannot be used simply because the patient may have four or five unaddressed and unrelated comorbid chronic conditions.

Second, extensive progress notes do not justify a complex visit for a problem-focused visit. That is, if an established patient is seen for pharyngitis, documenting an extensive history and physical of normal and negative findings does not expand that problem focussed visit (99212,99213) into a comprehensive visit (99215) simply because a volume of paperwork has been created. These are well outlined in the current Procedure Terminology Manual.

Another area of “upcoding” involves the use of procedure codes that do not necessarily match the clinical picture of the patient. For example, I recently reviewed a number of charts of a physician who was providing chronic wound debridement as treatment for diabetic foot and/or leg ulcers.

These patients were seen in follow up every two to four weeks. Each visit progress note stated that the ulcers were improving and decreasing in size, following the initial visit and debridement.

What was occurring with the billing, however, was that each visit was coded as a debridement; skin, subcutaneous tissue, and muscle (11043). Whereas the initial visit may have involved debridement of a leg ulcer to and including the muscle layer (11043), a follow up visit would have involved debridement of the superficial necrotic or granulation tissue: debridement; skin, partial thickness (11040).

This would certainly be true in light of entries in the progress notes stating improvement in both size and appearance with each visit. Also, when foot ulcers are debrided, the proper codes are for debridement of ulcer, foot; initial (X1101), and subsequent (X1102). Reimbursement is also different for the different parts of the lower extremity.

Even though a great many chart reviews are initiated by utilization or medical necessity issues, a significant number come about because of misinterpreted coding and billing procedures. It is incumbent upon the physician to be familiar with these as the physician is ultimately responsible.