Icd 10FraudEarlier this month, we talked about the potential for longer claims cycles as automated detection systems are temporarily derailed by the ICD-10 changeover. In our last post, we discussed mitigating the risk of being falsely accused of fraud by moving to ICD-10 as soon as possible and hiring an independent auditor.
Today, we’ll go into more depth on the steps practices can take to avoid a Medicare audit and how sophisticated coding software can guide you to the right levels of ICD-10 codes.
We’ll tackle basic processes first:
1. Use documentation best practices. Your clinicians and coders should be well trained and kept up to date on CMS changes and notifications. Emphasize the need for clear, careful, complete documentation. Auditors base their records reviews on what they see in front of them, not things your staff knows but doesn’t document.
2. Don’t create documentation after the fact. You should be performing self-audits periodically to see whether CMS program requirements are being met. However, you should not be tempted to retroactively fix mistakes when you find them. Use the self-audits as a learning/teaching tool only. If auditors suspect you are creating documentation for services that were already billed, you may face legal issues in addition to back payments.
3. Watch for “cookie cutter” procedures and outliers. Auditors look for uniformity, so recognize that few services take the exact same amount of time for every patient and that not every patient requires a particular diagnostic test. At the same time, if you are billing many more of a certain procedure than your competitors, this will be a red flag for auditors. If the outlying data is justified, make sure your documentation clearly supports this.
4. Pay attention to time of service, signature, and date requirements. For programs where documenting the start and stop time of the service is required, it’s critical to be accurate. Make sure none of your times overlap (and consider travel time), and always include both the start and stop times—if one is missing, the auditors will likely disallow the service. Similarly, auditors will often disallow all services that are part of treatment plan that was not properly signed or dated. Make sure all signatures are original (don’t sign a blank form and photocopy it).
5. Organize your records. On-side auditors will expect all records to be at your site and available. Finding the needed documentation after the auditors have begun asking questions about a patient record is not the way to go. Also, make sure to respond promptly and appropriately to all auditor requests.
On the technology side, there are steps practices can take to protect themselves, including using the General Equivalence Mappings (GEMs) developed by CMS to code in ICD-10. Used in conjunction with other CMS guidelines and a high level of coding expertise, GEMs can help you avoid coding improprieties.
Clearly, if you’re using coding software, it should includes GEMs. Allowing billers online access to clinical notes is another feature that can help with potential fraud issues—the key to coding to the highest possible level of specificity without over-coding is getting accurate information from the provider. To that end, if your system lets billers query physicians from within the coding system, you can gain an even higher level of accuracy on bills. This ability will be even more critical for accurate billing as practices move to ICD-10.
Overview of PracticeSuite Medical Billing Software

Last Updated on January 8, 2014