The Gist: “Upcoding” is a common form of healthcare fraud that attorneys, nurse consultants, records reviewers and experts may deal with. Knowledge of how coding is done is vital.

By Tommy Sangchompuphen, JD
for The Medical-Legal News

As automated and computer-assisted coding systems are playing larger roles in medical providers’ practices as a way to accurately capture all of the services they provide for reimbursement, claims coding professionals are warning practices — particularly their physicians who are becoming more directly involved in the coding process — not to lose sight of the fundamental principles of coding.

“Physicians can go to jail if their systems create fraudulent charges,” said Sheri Poe Bernard, vice president of member relations for the American Academy of Professional Coders.

“Physicians must have coding professionals who can ensure compliant output from any computer-assisted coding program they implement. Otherwise, they are putting their financial — and legal — future in the hands of an automated system that may not understand the nuances of regulatory requirements.”

Generally speaking, automated and computer-assisted coding systems are software that allows medical providers to quickly choose appropriate codes from a list of possible entries. Many doctors now use hand-held devices to access the coding software and select codes in both inpatient and outpatient settings.

“Automated coding systems are being implemented in the industry as a way to improve the manual process of coding in a variety of healthcare settings,” said June Bronnert, practice manager for the American Health Information Management Association, which represents coders and other health information professionals.

She added that while automated charge capturing systems have been around in the industry for numerous years and play an important part of a facilities’ revenue cycle, automated and computer-assisted coding systems are becoming more prevalent.

If used properly, automated and computer-assisted coding systems can become a valuable technological addition to capturing revenue that would have otherwise been lost under older, manual coding practices.

“Anything that has the ability to automate and to streamline and make more things efficient has the potential to become prevalent as time goes on,” said Barbara Scott, a professional coder and fraud examiner from South Carolina. “There is documentation out there that shows physicians lose revenue that they are entitled to. I don’t think insurers will argue that point.”

Bronnert agreed. “The goal of both the provider and payer is to have an accurate claim submitted and reimbursed,” she said. “There should not be a problem from the payer side to reimburse for a clean claim.”

But what some coding professionals are warning of is that insurers may likely have a sharper eye on those billing charges from medical providers utilizing these automated and computer-assisted coding systems as the potential for overcharging for unnecessary codes becomes an easier possibility as physicians become more directly involved in the coding procedure.

“I mean no disrespect when I say physicians are not coders,” Bernard of the AAPC said. “In fact, some physicians do their own coding and do it quite well. However, the rules around coding are complex. Physicians have enormous clinical responsibilities, and it isn’t good use of their time for them to immerse themselves in the administrative rules of medical coding and reimbursement. Professional coders keep abreast of coding rule changes and payer-specific rules just as physicians keep abreast of advancements in medical science.”

In addition, coding systems are “only as good as [the] developers,” Bernard said. Before adopting coding software, she said the providers should ask specific questions like does the development team include certified professional coders, does the program sort by payer rule set and is it updated continuously to maintain the latest edits and rules?

“No system has been developed that captures data flawlessly,” Bernard said, and a result, “upcoding can become a problem.”

Bronnert of the AHIMA suggested that each facility or provider evaluate its own workflow processes to utilize technology to meet the goals of the organization.

She said it is still important to have established compliance safeguards in place, such as pre- and post-bill audits, as audit trails are important to assess patterns. However, “these processes should be in place regardless of how the codes are assigned.

But, according to many coding professionals, one warning is universal.

“With the vast majority of these systems, responsibility starts and lies with the physicians,” Scott said.

“The physician is ultimately responsible for the claim form.” •

Tommy Sangchompuphen is a licensed attorney and legal writer based in Ohio. He is a graduate of the University of Minnesota Law School.