How Coders Can Help Prevent Healthcare Fraud and Abuse

Coding services are the life-blood of your practice. That is how the services you provide are transformed into billable revenue. It takes a knowledgeable and experienced coding staff to maximize your billed charges while maintaining strict compliance with CMS and CCI guidelines.

Coders are trained to identify noncompliance and fraud. Part of a coder’s job is to have sound knowledge in detecting ambiguous or suspicious documentation that could lead to fraud as a false claim if not detected before being submitted to insurance and being paid.

Fraud, in regard to medical coding, is when a false claim misrepresenting the facts is intentionally submitted to insurance in order to receive payment.

Examples of Financial Fraud are:

Billing for procedures that were never done
Knowingly billing for services at a different level than what was performed
Falsifying information in the medical record to satisfy the medical necessity

“You can’t code what is not there” – Meredith Tibbs, Medical Coder at MEREM Healthcare Solutions

Abuse happens when patients are treated with services that are not medically necessary

Examples of Financial Abuse are:

Billing for medical services that are unnecessary
Upcoding and Unbundling
Overcharging for supplies and services

Common terms of Fraud and Abuse in the coding world are:

Upcoding:

Reporting a higher level of service than what is supported in the dictation

Unbundling:

Reporting more CPT (procedure) codes than necessary to increase payment

Some higher paying procedure codes include smaller procedures in their code descriptions, so you can’t code both. You would only bill the one code that includes both procedures in the description.
It is very important for a coder to be familiar with these codes and stay updated when these change because they frequently do change and update these codes.

Medical Necessity:

The doctor must have a legitimate medical reason to perform tests and procedures
There are certain diagnosis deemed necessary for medical necessity attached to certain procedures. These have to be documented, you can’t make these up to satisfy the medical necessity

It is VERY important as a coder to be knowledgeable and confident in their field, so they are able to detect any potential risks that could negatively impact the facility and/or physician they work for as well as educate the people around them that don’t know.

“Staying up to date through compliance training either on their own or through their organization is of the utmost importance. Coders work too hard to earn their certifications and, in this field, honesty is ALWAYS the best policy.” -Meredith Tibbs, Medical Coder, MEREM Healthcare Solutions

Auditing can provide areas for improvement for your coding staff. Even a well-trained staff must be checked, therefore every practice should have an audit performed annually. An audit can recognize under coding, bad unbundling habits, and code overuse. Coding staff will then be able to bill appropriately for documented procedures.

MEREM Health specializes in auditing and can provide education, consultation, reports, and recommendations for improvement. The feedback and recommendations provided by our external auditors are valuable to the improvement of each practice.

Contact Merem Health today to find out how our auditing services will provide support for your practice!