The following is in response to Frank Cohen’s article at appeared in the September 20, 2012 edition of RACmonitor e-news.

Frank & Editor,

I would like to comment on the above article. First off, I think the article provides some “junk science” claims, since it does not provide accurate evidence to validate the stated claims. For example, the article claims that “findings of overpayments are not always due to something the provider may have done wrong, but often they are a result of the payer not doing its job correctly”. Really???? So it is the payer that actually bills the wrong codes for the provider, not the provider billing inappropriate codes. Would it be appropriate for criminals today to say that, they did not know the law, so it is the policeman’s fault.  Coding is the core of physician billing and not taught in majority of medical schools. I would recommend that physicians become certified in E/M coding. Do businesses start, when they do not know how to accurately get money for their services?  CERT reports, with 85% accuracy, has proven that the providers do not know what they are billing for and the documentation required to bill for stated E/M code.  Saying that the payer is not doing their job is inaccurate.  ICD-10 Monitor just published an article stating that medical schools should teach ICD-10 and CPT coding due to documented lack of knowledge on how to properly bill and document.

The “junk science” article mentions  a study that found that “1,700 physicians consistently billed for higher-level E/M services” and  states  “the OIG report, the issue revolves around a claim that physicians are now over coding-that simply lacks merit”.  The Center for Public Integrity recently reported that there was an $1 billion increase in Medicare spending due to high level E/M codes for emergency rooms. The high level E/M codes for emergency rooms has increased from 25% in 2001, to around 45% in 2008 nationally. The New York Times recently reported about an Illinois emergency room doctor noticed that his electronic software program automatically documented detailed histories and pulled examination findings from multiple patients, or “from thin air” called “cloning”.  The Department of Justice recently sent five major hospital trade associations a letter stating that they have found some troubling indicators that electronic medical records “cloning” documentation and “upcoding” of the severity of patient’s illness and the providers intensity of service, indicating that providers are “gaming the system”.  (382)

Providers have requested clear national guidelines years ago, but nothing has been provided yet. Since  providers and certified coders do not have 100% agreement regarding E/M codes,  the article suggests that maybe we should change the way providers are paid and I agree. We have seen that Medicare is moving toward paying for quality outcomes, which is ironic that healthcare is not totally focused on quality of outcomes. Since providers continue to have significant problems with accurate billing and coding,  Daniel Levinson, Inspector General recently stated that in the near future, all providers will be required to have effective compliance program.

Providers must acknowledge that compliance is not a department or person, but a successful business model. (491)

Patrick Guilfoyle RN, BSN, CPC

Medical Legal Consulting Services LLC.

Tabernacle, NJ


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