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5 Amazingly Easy Ways To Avoid ICD-10 Fraud Issues

Earlier this month, we talked about the potential for longer claims cycles as automated detection systems are temporarily derailed by the ICD-10 changeover. We’ll tackle basic processes on how to avoid a Medicare audit and how coding software can guide you to the right levels first:

How to avoid a Medicare audit:

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 a 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-site 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.

Importance of the right coding software: 

Coding for the right medical issue has always been complicated and the diverse range of codes don’t exactly make that easier. Insurance companies and hospitals now require high levels of detailed and specific coding in order for the right medical procedures to be recorded. A Forbes article by Tom Davenport discusses how the future of medical coding is interwoven with AI

1. More Codes, More Complexity

ICD-10 was implemented in 2014 and has over 14,000 codes for medical diagnosis. The World Health Organization has already released the next version of this standard ICD-11. Along with other countries, the United States will implement this in January 2022. ICD-11 is predicted to have over 55,000 codes – too many for any human coder to completely memorize. Even though the international standards update to far more complexity, there are now far more specific coding options for record-keeping purposes. This is even more the reason to ensure that medical coders are diligent in their job and not committing errors

2. AI-Assisted Coding

 The article references an experienced coder, Elcilene Mosley, who was initially suspicious that AI influences in coding would eventually put her out of a job. However, due to the complexity of medical coding codes and the patient medical history that is often needed alongside newer diagnoses and treatments, she believes that human coders will always be necessary.  She does admit that the integrated AI software has made her life easier when it comes to suggested codes. She says if coders are not careful, it could make them complacent and “lazy.”

3. Educating Coders

Mosley mentions that the biggest thing surrounding coder knowledge is the depth of knowledge and certification required. Herself, she holds an Associates in Medical Billing and Coding, as well as various field-related certifications. Her knowledge is tested often through units and tests. For new coders entering the field, she mentions how they are often oversold on success in the industry because hospitals and established practices are looking for individuals with experience. 

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