In October 2019 the practice wasfined $10,000 for the HIPAA violation. "Downcoding" is the polar opposite of "upcoding.". Section 103 of the No Surprises Act amended section 9816 of the Code, section 716 of ERISA, and section 2799A-1 of the PHS Act to establish a Federal IDR process that allows plans and issuers and nonparticipating providers and facilities to resolve disputes regarding out-of-network rates. Delivered via email so please ensure you enter your email address correctly. Undercoding can have a significant impact on individual physicians and group practices, too. May 11, 2022 Tags: Coding Denials Upcoding and downcoding are flip sides of the medical coding coin, and both can have seriously detrimental effects for healthcare providers and patients. No matter the price, physicians do need to know enough to do their own coding, LeGrand insists, and should not depend on billing staff or nurses. All rights reserved. Any accidental HIPAA violation that may qualify as a data breach must be treated seriously and warrants a risk assessment to determine the probability of PHI having been compromised, the level of risk to individuals whose PHI has potentially been compromised, and the risk of further disclosures of PHI. HIPAA Journal provides the most comprehensive coverage of HIPAA news anywhere online, in addition to independent advice about HIPAA compliance and the best practices to adopt to avoid data breaches, HIPAA violations and regulatory fines. No big deal, right? The second attack uses downcoding for a predicate singling-out (PSO) attack, a specific type of attack against data anonymization standards under the European Union's privacy law GDPR. Suits that include claims for downcoding, bundling, and other forms of underpayment, nonpayment, and late payment have been asserting violations of the Racketeer Influenced, and Corrupt Organizations Act, fraud, misrepresentation, and--as used in the CIGNA case--breach of contract. In all other cases when there has been a breach of unsecured PHI, the incident must be reported to OCR, and individuals impacted by the breach should be notified within 60 days of the discovery of the breach. That means that about 40 percent of the CPT codes used opened the practices to allegations of fraud. Thats only a $26 difference. 1) An unintentional acquisition, access, or use of PHI by a workforce member or person acting under the authority of a covered entity or business associate, if such acquisition, access, or use was made in good faith and within the scope of authority. Practically every breach in the Laptop or Other Portable Electronic Devices categories relates to a stolen or lost device. Medical coding is the life-blood of a practice. Most organizations facilitate anonymous reporting of HIPAA violations; so, if you are concerned about the future relationship with your colleague, this may be an option for you. When physicians hear about [audits and prosecutions] it triggers them to bill low. No. The sharing of login credentials contributed to a $202,400financial penalty for the City of New Haven in Connecticut. The use of any trade name or trademark is for identification and reference purposes only and does not imply any association with the trademark holder of their product brand. Spend a few bucks and learn how to code, and youll be a happy camper; youll make more money and sleep better at night.. By 1997, nearly every provider in the country was expecting federal investigators to knock on his or her door at any minute - and the situation hasnt gotten much better. Another important aspect to keep in mind is that under coding establishes false utilization patterns, which in turn may flag a physician as an outlier, making him or her a target for payer investigation and/or audits. How should healthcare employees, covered entities, and business associates respond? Once you start practicing, it is important to understand who the payers are. Outsource!). Omitting documentation of those 45 minutes of critical care time means a lost opportunity to code for not one, but two segments of CPT code 99292a loss that translates to a payment that is about 20 percent less than it should be. To get credit for taking the history for an established patient, all you need to do (according to HCFA regulations) is review the existing record and update it to reflect any changes. If the accidental violation is indeed a violation of HIPAA, the Privacy Office will need to determine whether or not the violation constitutes an impermissible use or disclosure which qualifies as a breach of unsecured PHI. Downcoding also potentially signals HCFA about irregularities in your practice. what does encrypted data look like to unauthorized users. In most cases, events that result in impermissible disclosures or breaches of unsecured PHI will require an assessment and investigation. New evidence shows how drastically provider angst has impacted coding - and physician revenue - over the past five years. Its impact is given as follows. Henley, executive vice president of the American Academy of Family Physicians, estimates that family physicians, who are most likely to be familiar with coding regulations, lose 10 percent to 30 percent of their total revenue through incorrect coding. Worse, it is costing practices a ton of money. In many cases, however, the diagnosis codes that private plans assign to their enrollees to report their health status make the enrollees appear less healthy than they actually are. Downcoding makes physicians lose money. All aspects need to work together just right and at the right time or the system breaks down. Here's how to avoid it. Just as history-taking can be simplified, so too can the process of documenting your exam work. If the HIPAA violation is not reported (to HHS Office for Civil Rights and the subjects of the medical records), the risk assessment has to be maintained for a minimum of six years. Let our consultants provide you with a free tool to help improve your current revenue process. Coding patterns have shifted dramatically - from higher-level codes to lower-level ones. The incident will need to be investigated, aHIPAArisk assessmentmay need to be performed, and a report of the breach may need to be sent to the Department of Health and Human Services Office for Civil Rights (OCR) and the affected individual. CPT Code Revision Updates The AMA's work on streamlining documentation and reducing note bloat is far from over. Government funded health care programs, like Medicaid and Medicare, have adopted specific billing . 4 II. Monitor payers' changes of your codes or downcoding of claims for frequency and patterns. They should use the documentation regs as a safe harbor. Failure to code correctly could directly impact a patients treatment. Compliance Junctions Under the now-delayed policy, claims that are determined not to be tied to emergencies would be subject to no coverage or limited coverage based on the patients insurance plan, according to the insurers notice sent to hospitals. If you prefer, use a nurse or physician assistant to ask the patient the relevant questions, as long as they are answered. CPT is a registered trademarks of American Medical Association. And it provides another example: According to testimony by the Central Billing Office (CBO), hospitalized patients with respiratory infections are generally assigned to one of two diagnosis-related groups: respiratory infection or simple pneumonia. A report of an accidental HIPAA violation would need to be sent to the Department of Health and Human Services Office for Civil Rights (OCR) if it results in the unauthorized disclosure of unsecured PHI for example, an email containing PHI being sent to the wrong patient. However, the agency does consider downcoding an incentive for more frequent patient care, comments Nancy Reading, clinical analyst at the American Academy of Professional Coders. Physicians routinely look a patient in the eyes searching for signs of illness; in fact, they do it so routinely they may not really recognize it as part of an exam, and therefore dont record their action. If someone accidentally violates the Privacy Rule and is aware they have violated the Privacy Rule it is better for them to admit the error to a supervisor or their Privacy Officer so any potential consequences can be preempted (i.e., a complaint to HHS Office for Civil Rights). HCFA uses profiling to identify groups for audits; if your coding is significantly different from others in your state and specialty - whether its lower or higher - youll stand out. Learner-Friendly HIPAA Training, Get Free Access To ComplianceJunctions HIPAA Training Platform With A Selection Of Their Learner-Friendly Modules, Learn More About Compliance Junctions HIPAA Training Pricing For Organizations, Individuals And Universities, Show Your Employer You Have Completed The Best HIPAA Compliance Training Available With ComplianceJunctions Certificate Of Completion, Learn About Compliance Junctions Learner-Friendly HIPAA Training For Healthcare Students, Find Out With Our Free HIPAA Compliance Checklist, Free Organizational HIPAA Awareness Assessment, financial penalty for the City of New Haven in Connecticut, The Seven Elements Of A Compliance Program, The potential for re-disclosure of information, Whether PHI was actually acquired or viewed, The extent to which risk has been mitigated. Practices and providers who have a history of coding mistakes may face fines and or federal penalties for fraud or abuse. The HIPAA Rules require all accidental HIPAA violations, security incidents, and breaches of unsecured PHI to be reported to the covered entity within 60 days of discovery although the covered entity should be notified as soon as possible and notification should not be unnecessarily delayed. How quickly are your claims being followed up on upon initial denial? Your HIPAA Privacy Officer has the responsibility to decide what happens next in terms of mitigating the consequences of the violation and whether the accidental HIPAA violation justifies a sanction. Regardless of how they train themselves to do it, physicians should try to dictate in a way that supports current coding, not the old-fashioned subjective, objective, assessment, plan (SOAP) protocol. This form of undercoding is often the result of incomplete or inaccurate documentation. Generally, there is no such thing as an intentional but acceptable HIPAA violation. The cases of simple pneumonia rose by 42,000. Especially, she notes, they tend to forget to document normal findings. Coders and providers (rightly) worry about upcoding, or coding at a "higher level" than supported by documentation or medical necessity; however, "downcoding," or coding at a level lower than the level or service supported by documentation or medical necessity, is equally damaging, from a compliance perspective. For example, if a patient is diagnosed with asthma and is treated for it, the coder may submit a code for a less severe condition, such as bronchitis, to get the claim paid. Physicians are throwing their money away. But LeGrand agrees that physicians generally dont give themselves enough credit. You dont want to take advantage of the system.. Luckily, a growing number of physicians are fearlessly coding correctly, determined to make what they deserve. A miscoded procedures reimbursement has the potential to differ by up to $15,000. After the OCR investigation, computer monitors were also repositioned to prevent the accidental disclosure of PHI. It has nothing to do with good patient care, Welter agrees, but you still have to do it. Following the risk assessment, risk must be managed and reduced to an appropriate and acceptable level. However, the sharing of login credentials is not permitted by HIPAA as it makes it impossible to track information system activity accurately. If you accidentally violate HIPAA, and nobody notices, it is still in your best interest to report it. However, there are a number of exceptions. Upcoding disadvantages patients as they are forced to pay for services they never received. To document for a 99214, then, show that you met those criteria. Compare one physician in a group to another in the same group. Step 4: Implement Checks and Balances in the Billing Process. Undercoding is damaging to your practice from a compliance perspective. In a Thursday statement, the Minnesota-based insurer said the policy will be halted until the end of the pandemic. For example, practitioners who undercode might be more likely for an audit if their services are consistently below average. Many providers default to diabetes without complications. If audited, they may not have the documentation they need to support their coding patterns. LeGrand suggests one way to improve documentation is to follow a template listing all systems and elements of the exam. Todd Welter, president of R.T. Welter & Associates, a consulting group in Denver, reports that, when he lectures on coding, physicians regularly come up afterward and privately say, I always pick a lower level of service on purpose because I dont want to get in trouble., Douglas Henley, MD, who practiced as a family physician for 20 years, thinks all physicians downcode, feeling that that is a safe harbor.. Giving them the opportunity to report the event first reduces the risk of your relationship being damaged. That coding may not be appropriate.. With 90% of symptoms overlapping between non-urgent and emergent conditions, in many instances even physicians cannot know if a patients symptoms require emergency treatment without conducting a comprehensive medical examination, the physiciansgroup said. An accidental disclosure is not a HIPAA violation in every case. You will need to explain which patients records were viewed or disclosed. Templates should function as a customizable guide to documentation and dictation, she warns, not as a replacement for them. Author. Of course, HCFA, busy as it is, is unlikely to come after a provider for undercharging. If you learn the system, [documentation] actually is less work, Welter insists. A 99213 is used for an expanded exam, one in which at least one system is examined fairly thoroughly - the physician must review at least six elements of the system - and that demands at least some medical decision making. To code a 99214 (a detailed exam for an established patient), for example, a physician must review at least two items from six systems, or at least 12 items in two systems. The national emergency physicians group believes the delayed policy is in direct violation of the federal layperson standard, according to a June 8 statement about UnitedHealthcares new policy. Professional coder or not, if they are not keeping up with the nuances for your specialty, there is no use to either one of them, she says. It is important to understand the consequences of these coding errors and it may be a wise investment to consider outsourcing medical coding toan experienced service provider. Welter reports seeing charts with plenty of ink but all the wrong information. Outsourcing also frees up a great deal of time, allowing practitioners more time with patients. Implementing internal controls to detect . This back up of denials due to coding errors requires focused efforts to catch up on claim denial and improve your revenue cycle. Downcoding is a defensive approach used by certain providers to prevent refused claims, audits, and other problems. But if you downcode to the 99212 two times a week, it costs about $2,496 per year (assuming a 48-week year). Not only does downcoding create a negative financial impact, its also not really any safer, as far as federal regulations are concerned, than overcharging. 2. flat rate by claim or monthly fee. In the notice to hospitals announcing the now-delayed policy, UnitedHealthcare says emergency room claims will be evaluated based on the patients presenting problem, the intensity of diagnostic services performed and other patient complicating factors and external causes. Medicare payments for the former averaged $7,400 in 1998; payments for the latter averaged $4,900. A 99212 is, generally, a $29 payment, while the 99213 runs about $55. Risk Adjustment / HCC Coding Course (RAC), ICD-10-PCS (Inpatient Procedural) (40 Hour Course), Medical Terminology & Anatomy (MTA) (Full Course), How to Pass the CPC Exam Tips & Strategies, How to Get Started in the Lucrative Medical Coding Field, How to Prepare For Your First Medical Coding Test, Test Your Practice Management IQ Checklist, Understanding E/M Coding Step-by-Step Guide. A patient complaining about pain in her left foot does not benefit from examination of her eyelids. Cite official sources to support your position. Because ofICD-10, sets of more specific codes have been implemented and the CMS modify codes on a quarterly and annual basis. Freaked out by the mere thought of a federal audit - and the threat of stiff fines and possible jail time - physicians across the country are consistently billing Medicare (and other payers) for a lower level of service than they actually provided. This is often due to oversight, but some practices intentionally undercode to avoid an audit. No business associate agreements were in place, no patient authorizations were obtained, and those disclosures were therefore impermissible under HIPAA. Technically, submitting an inaccurate bill is submitting an inaccurate bill: It is a false claim whether its false because it is too high or too low. States push ahead on public health insurance to lower costs, improve access, told its network hospitals in 34 states that it will assess emergency room claims. In a further example of an unintentional HIPAA violation listed on the OCRs website, staff were required to undergo HIPAA training due to one member of staff discussing HIV testing procedures with a patient in a waiting room thus disclosing the patients PHI to other patients in the waiting room. Get data on how many new patient, established patient, and consult visits each physician billed, and at what level. The fear factor in physician billing first emerged in 1995 with the launch of Operation Restore Trust, the Health Care Financing Administrations (HCFA) pilot program in fraud prevention. HIPAA Advice, Email Never Shared In two or three years, people who are coding correctly will appear to be upcoding, Welter warns. If you accidentally break HIPAA rules, the consequences depend on how the rules were broken, what the outcome was, and your previous compliance history. In other words, the purpose of the benchmarking exercise is not to say, Oh, national data says I need 47 percent level three, new patient visits. However, incidental disclosures of any other type are reportable events even when they are accidental violations of HIPAA. If a colleague has accidentally violated HIPAA, but not reported it, your first course of action should be to speak with the colleague. And dont worry too much about the cost of a good class: A good, solid investment in learning how to bill correctly is less expensive than leaving money on the table or being pursued for a false claim, LaFond points out. 3)If the covered entity or business associate has a good faith belief that the unauthorized person to whom the impermissible disclosure was made, would not have been able to retain the information. However, although this may not be a HIPAA accidental violation, it may count as an accidental violation of state privacy rules. Are your ready to improve your revenue cycle while avoiding the consequences of coding errors? "Based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period," Tracey Lempner, spokeswoman for theMinnesota-based insurer, said in a statement. 3. patient date of birth and gender. Physician Relationships With Payers. If this were to happen, it would most likely be the case you have a history of accidental HIPAA violations and have received prior warnings about what might happen when you next violate HIPAA. This is also known as undercoding and usually results from insufficient documentation. The fax you have received in error should be destroyed without delay. Not only will your report indicate your willingness to be a compliant employee, but the circumstances that led to the accidental violation may have been overlooked in a risk assessment. It is a reportable HIPAA violation when lost medical records are found unless it can be demonstrated by way of a risk assessment there is a low probability of the medical records being compromised (accessed, viewed, or amended) and, if so, of being further disclosed. Back to the basics: Post-pandemic enforcement of coding compliance issues. According to the survey, physicians upcoded 19 percent of the time and downcoded 21 percent of the time. Accidents happen. While any complaint about a privacy violation should be flagged to management, if the patients privacy has been violated by a member of a Covered Entitys workforce and involves an impermissible disclosure of PHI, you should contact the organizations HIPAA Privacy Officer. Include questions about all major systems. In such cases, records can be provided minus the psychotherapy notes. Similarly, the American College of Emergency Physicians said it fearedthe change would cause patients to avoid using emergency rooms because they will be responsible for their hospital bills when UnitedHealthcare rejects them. For example, forgetting to document a patients agreement to be included in a hospital directory is not a violation of HIPAA but could be a violation of the hospitals policies. Upcoding is a fraud that involves billing payers for more expensive procedures and treatments than those provided. Regulatory Changes Subscribe for Updates When it comes to medical coding errors, they fall into the broad categories of "fraud" and "abuse." The former involves intentional misrepresentation. There is a consensus to consider this rule of payment as the least likely to be manipulated by the actors. UnitedHealthcare is expecting patients to self-diagnose a potential medical emergency before seeing a physician, and then punishing them financially if they are incorrect, Rosenberg said. One of the largest causes of medical coding errors is due to inadequate medical documentation. The easiest way to take a medical history is to ask a new patient to fill out a standard history form. But where to start? It may be possible they were unaware they had accidentally violated HIPAA or they may have some other reasons for not reporting the violation. Use any form on this page to arrange for your copy of the checklist. To prove fraud occurred rather than abuse, the upcoding or miscoding of an event must occur over time and across a large number of patients. All rights reserved. Document Automation, Data Extraction for Independent Practices. It entails under-billing patients. COVID was a tipping point for telehealth:If doctors and patients have their way, virtual visits are here to stay. All product and company names are the registered trademarks of their original owners. If they just take the time to read [the rules] and to implement it, theyd be more comfortable coding at the appropriate level, Henley says. Term used when the insurance carrier bases reimbursement on a code level lower than the submitted by the provider. 9 Upcoding occurs when a healthcare provider submits codes for more severe and expensive diagnoses or procedures . Look for the link to 1999 Procedure Code Utilization by Specialty. If medical information is sent to the wrong person by mistake, it only counts as a HIPAA accidental disclosure if the sender of the medical information is a member of a Covered Entitys workforce. The federal policy requires insurance companies to provide coverage of emergency room care based on the presenting symptoms that brought the patient to the emergency room and not the final diagnosis, according to the physician group. MedPACs understated report to Congress summarizes, Part of the response to fraud and abuse policies has been less aggressive billing by healthcare providers..
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