Posts Tagged Coder

“We Need to Talk”

[Added Edge]

Cultivate communication with your physician.

By Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC

Let’s talk about the relationship coders have with their physicians. Physician and coder communication is vital to that relationship; yet, we often don’t cultivate it.

Understand the Perspective of a Doctor

Recently, I sat down with Edward L. Birdsong, MD — a hand and upper extremity microvascular surgeon at the Allegheny Health Network, Orthopaedic and Rehabilitation Institute in Pittsburgh, Pa. — to discuss this topic. We didn’t talk about bundling, global periods, or add-on codes. Instead, we considered the following questions:

  • How should coders start a conversation with his or her physician?
  • How do coders and physicians learn from each other?
  • What kind of a rapport should physicians and coders have?

“I would welcome a meeting with my coder, at least once a week, to discuss op notes and how to bill for the services I perform,” Birdsong began. “Let’s see if we are on the same sheet of music,” he continued. “We can’t make music if the instruments are out of tune. We can’t bill for a service if the documentation doesn’t match. Let’s help each other to document appropriately and bill for the services performed.”

As we talked, I learned that physicians do not always know how to properly convey in their notes the services they provide. Many physicians do their own coding, and the codes may accurately reflect the work they did, but the documentation may not match the codes.

“Operative notes are often a list of procedures performed during given operations, along with a narrative explaining what occurred,” Birdsong explained. “If I had a way of conveying the information needed to actually code all of the services I perform during surgery, I would certainly incorporate that information.” He continued, “If there was a meeting where the coder and the physician go over a few notes, each week, and really listen to what each other is saying, the notes could be more descriptive to better illustrate the work performed.”

In my career, I often hear from coders who were told by their managers to do anything they could to get clarification — just don’t bother the doctors. I asked Birdsong how he felt about this.

“I don’t mind, ever, having a coder ask me a question. I know I’m going to learn from the question, maybe even more than the coder learns from my answer,” Birdsong said.

Dialogue Benefits Everyone

Physicians want to learn, Birdsong said. “They may not have a lot of time — nor do the coders. But if they could find time to meet regularly, it would benefit everyone. We know that there might be a slight period of adjustment with these meetings, but that doesn’t mean they’re not worth the effort,” he said.

Birdsong suggested that coders offer courses to the physicians on how to document, and what the codes mean. “If we all understood each other’s piece to this pie, we would all be better for it,” he said.

What would the benefits be? For one, doctors would document better. Secondly, reimbursement would be more appropriate. If reimbursement was in line with what was actually performed, denials would go down, refunds and re-bills would be limited, the revenue stream would be more constant, and everyone might actually have a little extra time on their hands. We agreed the final point was very important.

Birdsong also mentioned that meetings would open the lines of communication. “I might be saying exactly what the coder needs, but I’m not saying it with the right terminology, or it’s not understood. If we both — the physician and the coder — agree to learn from one another, the communication would be free flowing. Understanding things in the same way will get us where we need to be.”

Spell Out Code Requirements

Birdsong confessed that not only he, but also his colleagues, could learn from coders. “The coders could focus on teaching the physicians the appropriate way to illustrate what was done during the operation.”

For example, the evaluation and management (E/M) guidelines spell out what must be documented to report E/M services. “If we could have something similar for our more common procedures, it would be a great help,” Birdsong suggested. “If the coder could develop a list of the requirements needed for the codes associated with the procedures, I would use that to make certain I cover everything appropriately.”

In a previous role, Birdsong had a colleague who, with help from his coding staff, developed a documentation checklist that proved very helpful and easy to follow. This helped illustrate to the physician details that he didn’t realize the coder needed, and therefore didn’t document—but now he does.

Shadowing Can Help
Open Communication Lines

Shadowing is another very helpful and appreciated way for physicians to learn from the coder (and vice versa). Yet, this is a frequently missed opportunity, especially when the communication between the coder and the physician is discouraged.

“When I first got here, an auditor shadowed me, and I learned a lot,” Birdsong said.

Shadowing has been greatly educational for me, as well, and has improved my ability to communicate with physicians. I have a better understanding of how their day moves, and when they have time for documentation. I also witnessed patients providing information to the physician that was beneficial, and became part of the physician’s decision-making, but didn’t make it into the documentation. I demonstrated how the documentation guidelines flowed with the visits, and how “showing your work” in the visit note will help to prove the medical necessity for the services the physician provides.

Coders Help Doctors
Gain Optimal Reimbursement

Birdsong noted how busy his days are. Some of the vital things physicians do for patient care can’t be billed (talking with family, scrubbing and prepping for surgery, documenting, etc.). But communication with coders ensures he is able to gain optimal reimbursement for those services he can bill, by documenting to reflect exactly what happened during a case, a visit, or a counseling session. “If I make the requirements a habit, everyone wins,” Birdsong said.

I asked Birdsong what he wanted most from his coder. Birdsong immediately answered, “Communication!” Emails work, as do questions in the hall, he said. “If my door is opened, I’m in the office and available to anyone.”

Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, is manager, physician compliance auditing for Allegheny Health Network, Pittsburgh, Pa. She serves on the OptumInsight Advisory Board and is a Coding Institute Editorial Advisory Board member. Hauptman is a former AAPC National Advisory Board and AAPC Chapter Association board of directors member. She speaks and writes nationally for organizations such as the University of Pittsburgh, The Coding Institute, Advanced Career Solutions, AAPC, MGMA, BC Advantage, and OptumInsight. Hauptman is a member and former president of the Pittsburgh Central, Pa., local chapter.

June 1st, 2014

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Be an Attractive Candidate for a Hospital Coding Position


Be ready if a hospital employment opportunity arises in a facility near you.

In our changing health care environment, there may come a time when you need to look beyond your physician practice and branch out in another direction. For example, based on the latest trend, your practice could be bought out by a hospital. If that happens, you’ll need to be able to prove you’re a viable candidate to hospital coding managers. However, many physician trained coders find hospital requirements very different and the transition difficult. You’ll have a much easier time if you are prepared, and a good place to start is by reviewing the hospital revenue cycle, which has significant differences from that of the physician office.

Review the Hospital Revenue Cycle

There will be differences between facilities in regards to the revenue cycle, depending on the size of the facility and whether they are for profit or not for profit. Typically, however, the chief financial officer looks at the hospital’s revenue producing departments and establishes certain monetary monthly goals for that department using service utilization, patient flow, and other data. The chief revenue officer typically determines a positive or negative outcome for each revenue-producing department using various reporting programs. If a department has an income deficit, this prompts a close look at why the deficit has occurred. There can be many reasons, but if the department does not produce expected revenue, particularly if the deficit occurs frequently, the department’s management must give an accounting of why and how he or she plans to improve the deficit.

The revenue cycle starts in Patient Access and moves to Benefits Verification. These are critical steps in obtaining correct demographic information, determining whether services will be covered, and calculating patient responsibility amounts. Errors in these steps usually have a ripple effect. If the patient is admitted as an inpatient or into observation, typically, case management is responsible for monitoring the stay and determining if the stay meets inpatient criteria and (if a Medicare patient) whether there is adequate inpatient days to cover the stay. If an observation patient is converted to inpatient status by the physician, this group will advise Benefits Verification that new authorization for inpatient services is necessary.

Understand Your Role in the Hospital Revenue Cycle

The next step in making yourself marketable in the hospital environment is to determine your role in the revenue cycle. The health information management (HIM) manager ensures that attending physicians complete the patient records in a timely manner and records are ready for the coders. Here is where a physician trained coder must be ready to shift gears. Regardless of what you are initially hired to do, you must realize that at some point, you will need to code inpatient records. This is where the money is for hospitals, so inpatient records take priority over outpatient encounters, even if outpatient coding is your normal assignment. To prepare for this new assignment and to stand out as a candidate for inpatient coding:

  • Be proactive in showing an interest in learning inpatient coding.
  • Take time to look at inpatient records coded by inpatient coders.
  • Realize that inpatient and outpatient coding guidelines are somewhat different.
  • Become very knowledgeable about coding conventions and guidelines in the front of your ICD-9-CM coding book. This is how hospital coders are expected to code the records. Encoders that are structured for hospital use will also assign codes based on these conventions. National Correct Coding Initiative (NCCI) edits are included in the encoder and generally flag the coder to look closely at two reported codes. Coding Clinic and CPT® Assistant are normally sources available within the encoder.
  • Understand that CPT® is not reported on inpatient records. Procedures are coded using ICD-9-CM Volume 3, and there is not a direct crosswalk between CPT® and Volume 3. To assign codes from Volume 3, ask yourself: Is the procedure surgical in nature? Does it carry a surgical or anesthetic risk? Does it require specialized training to perform the service? If your answer is yes to any of these questions, a code is assigned. Using this information, take a look at some familiar CPT® codes and determine how the service might be reported using Volume 3. A reasonable rule of thumb is that if CPT® describes multiple steps, often more than one code from Volume 3 must be used to report the same service.
  • Know that hospital coders report all conditions that the physician manages or affect the management of the patient. Inpatient records may require 10, 15, or even 20 diagnosis codes.
  • Realize that sometimes there are different reporting protocols in CPT®, depending on whether you report for physician or facility services—infusions are a good example. Review the reporting hierarchy for facility infusions in your CPT® codebook to see how they differ from physician reporting.
  • Be aware that facility evaluation and management (E/M) reporting is captured only in the emergency department and in facility clinics. History, exam, and medical decision making (MDM) are not factors in facility E/M; levels are determined based on use of resources and assigned based on a point system. Each facility typically determines their own point system; however, the service must be documented in the medical record, meet medical necessity, and be reasonable in the point assignments. Look at outpatient modifiers 73, 74, and 27, used by facilities, and know when these modifiers are applicable.

Understand How Charge Description Masters Are Used

In assessing your qualifications, hospitals may also look at your knowledge of charge description masters (CDM). Facilities establish services in the CDM that are charged to the patient’s financial record and are entered usually by the department performing the service. Hospital coders typically code for all diagnosis coding, surgical procedures, and infusions. They may code for other services, depending on if the service  is already embedded in the CDM. Your coding manager will advise of these services, but typically drugs, supplies, laboratory, radiology, and anesthesia are not coded by the hospital coder. Some clinics, such as pain management, may charge through the CDM or be coded by a coder, depending on how the hospital handles these functions.

Another important thing to remember: The physician is not available to clarify documentation; and you will not be able to use charge tickets, encounter forms, or super bills for coding assistance.

Meet Productivity and Accuracy Standards

Accuracy and meeting quota also may factor into whether you are a good candidate for hospital coding. When the coding department experiences a backlog of records for coding, the manager must take action to bring the records current. This is a good example of when an outpatient coder may be asked to code inpatient records, and why hospital coders are held to productivity and accuracy standards. You will be held to these same productivity standards.

Although there may be slight differences, depending on expectations of the coding manager, typical coding time is approximately:

  • Inpatient records: 18-20 minutes. This includes all diagnosis codes, Volume 3 codes, assigning the present on admission (POA) indicator, and abstraction of the record.
  • Ambulatory surgery records: 7-10 per hour
  • Emergency department records: 20 per hour
  • Referral encounters (example: patients coming for lab, X-ray): 30 per hour

These numbers translate to three minutes for emergency department records and two minutes for referral encounters.

If you are given a pre-employment coding test, the coding manager will not only look at accuracy, but whether there is reasonable expectation you can reach these production standards by the end of the normal 90-day probationary period. When records are not coded quickly, the entire revenue cycle is affected, in billing, insurance follow up, and other collection efforts. Accounts receivable days are closely monitored by hospitals, and are a primary measure used to determine their financial health. Slowdowns and backlogs of the revenue cycle directly affect the revenue stream. Time spent collaborating with other coders must be kept to a minimum if you intend to meet your productivity requirements.

Seek Training

When I speak with physician coders about transitioning to hospitals I am asked, “Where can I obtain this type of training?” Here are some ideas that may be helpful:

  • Invite someone from your hospital to present at a chapter meeting. If a coding professional is not available, use someone from the billing or revenue cycle department.
  • If there is a community college in your area that has a HIM program, invite someone from that program to speak at a chapter meeting.
  • Use Quality Improvement Organizations (QIO) as a resource. They review disputes between Medicare and hospitals about correct Medicare Severity Diagnosis Related Groups (MS-DRG) assignments and necessity of inpatient admissions. They may send coding disputes to a contracted coder for supporting opinions, but they have already done an in-house review prior to that step.
  • If you have a hospital-based member in your chapter, ask that person to help you get training underway.

Interested in implementing physician-to-hospital coder training in your chapter? Based on the three-day workshops I present, training might begin with an overview of hospital coding and billing on day one. On days two and three, activities might include hands-on coding of sample hospital records—reviewing accuracy and looking at how quickly coders can determine codes and POA indicators. Consider holding sessions on three consecutive days or on three separate Saturdays. Something else to consider: This is a good opportunity to collaborate with another chapter to arrange a group session.

Sell Yourself Using Knowledge and Adaptability

Through my experience when speaking with hospital managers about an ideal candidate, they often mention the need for coders to be able to code multiple types of records, meet productivity standards, and be familiar with hospital encoders. You may not have an opportunity to use encoders unless you are actually in a hospital, but you can focus on building efficiency in multiple encounters, being open minded, and knowing that you will need to meet productivity standards.

Take advantage of opportunities to learn the facility side of coding. Realize hospitals provide many more services than physician offices. If general surgery is your specialty, it’s likely you’ll need to code for many other types of services. Hospitals in smaller towns may be more lenient when using a physician coder, but you should still sell yourself in an interview by showing you are ready for the challenge. If you welcome the opportunity and are proactive in learning about the facility world, doors that are not easily opened will open for you.

Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, RCC, RMC , is a technical college instructor in Atlanta and an independent consultant, performing physician audits and education for the Quality Improvement Organization in Georgia. Her 34 years of experience in health care includes working as a Medicare specialist for a large hospital system, as well as contributing to various medical publications, presenting at health care conferences, and developing training classes on facility billing, coding, and reimbursement.


March 1st, 2013

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What’s Your Repayment Obligation Under the FCA?

After the 2012 AAPC National Conference, a question was presented to AAPC’s Legal Advisory Board:

Q: I recall a question and discussion at AAPC’s National Conference in Las Vegas about the coder/consultant who is aware of an overpayment. It seemed to me that your guidance could be interpreted to mean the individual had no obligation to recommend repayment of the overpayment (and should even avoid making such a suggestion in the audit report to his or her client). The highlighted language below might suggest otherwise:

Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, responds:

I understand your point and am very familiar with the statutory provisions and the case law interpreting and applying this provision. This is commonly referred to as the reverse False Claims Act (FCA).

You must consider who is a proper party for FCA analysis in the example we dealt with. The coder is not a recipient of money from the government relative to services performed and reported by the provider; therefore, he or she has no direct obligation to repay an overpayment received by the doctor. For that same reason, a coder knowing of an overpayment—as long as he or she doesn’t collaborate to actively conceal the existence of an overpayment—has no obligation to contact the government if the provider refuses to refund. Even in the case where the overpayment is clear and the provider refuses to refund, a coder’s obligation and liability ends with identifying the overpayment to the provider. It is not a coder’s obligation or duty to advise the provider of his or her legal responsibilities under the FCA. The provider is charged with such knowledge. A “heads up” or suggestion by the coder to contact health law counsel would not be inappropriate, but it is not required. To suggest a coder has an obligation to report such conduct to the government would be to eliminate the purpose of the incentive provisions of the qui tam statute.

Returning to the question, “What should a coder do in a situation where he or she believes an overpayment has been received—for example, as a result of an internal audit?” At national conference, I suggested simply reporting the findings to the provider. I also recommended that the provider could either have the concern evaluated independently if there was some disagreement about the internal audit results. In such a case, involvement of health law counsel is a good idea. Either way, if the overpayment is real, the provider will likely need assistance with the disclosure. If the provider refuses to refund, that decision and the resulting consequences rest solely on the provider.

An offshoot question was also discussed where the conduct arose out of claims to a purely commercial carrier. Usually, there is no legal duty to disclose, as similar to the duty for federal plans under the FCA. I suggested at the conference that it’s a good idea to disclose and refund any known overpayment. The coder’s obligation, however, remains the same. Report the findings to the provider or compliance officer. A provider who demonstrates a willingness to refund where appropriate is not only likely to be perceived more favorably by the carrier, but the fact that the provider willingly disclosed such overpayments when they became known may become useful evidence in the face of some future fraud allegation. Plus, it is simply the right thing to do.

Q: You seem to be relying on the “conceal” part of the statute. I’m more concerned about the “knowingly and improperly avoids or decreases an obligation to pay” language. 

I also don’t understand the importance of there being a “legitimate disagreement” between the parties. Are you suggesting a “legitimate disagreement” forms some sort of FCA reporting requirement threshold?

What if the facts are established and changed around a bit? Let’s say the coder works for a large group practice. The coder reports the overpayment to the compliance director. Does the compliance director’s liability also end when he or she identifies the overpayment to the group practice’s provider or board of directors?


To answer your three questions:

  1. Knowing and improper avoidance is connected to an obligation to repay. A coder would have no such obligation to repay; only the provider would.
  2. With respect to circumstances when there is a disagreement: I have been involved in a number of cases when a coder, biller, or other staff member raised an issue indicating that payment was inappropriate. Investigation revealed that the staff member either misunderstood the situation, misapplied the relevant rule, or applied a principle or standard that did not apply. In such a case, the provider has a legitimate basis for not disclosing the alleged error and refunding.
  3. In response to your hypothetical question, the answer is, “Yes.” The compliance officer or director has no obligation to personally repay the money that was inappropriately received. The compliance director also cannot be charged with inappropriately retaining the money because he or she is not likely in control of the money. If the compliance director had such authority and responsibility and failed to disclose, then there might be personal liability. More commonly, the provider or group would get tagged with FCA liability where it was discovered the provider or group knew of the overpayment, and knowingly and improperly retained the money.

Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, has a bachelor of science degree from the U.S. Military Academy, a juris doctorate degree from Concord Law School, is president of Practice Masters, Inc., and founding partner of Miscoe Health Law, LLC. He is a past member of AAPC’s National Advisory Board and a current member of the Legal Advisory Board. He is admitted to the Bar in California and to practice law before the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. He has nearly 20 years of experience in health care coding and over 15 years as a coding and compliance expert testifying in civil and criminal cases. He is a national speaker and has been published in numerous national publications.

September 1st, 2012

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Is Your Credit History Preventing You from Getting a Job?

For some, having coding credentials and experience isn’t enough to guarantee a job in a physician’s office. It may require a good credit history, too.

In 2010, the U.S. Equal Employment Opportunity Commission conducted a public meeting to explore the use of credit histories as employee selection criteria. During that meeting, Christine V. Walters of the Society of Human Resources Management said, “13 percent of organizations conduct credit checks on all job candidates … [and] another 47 percent … consider credit history … for select jobs.” (more…)

March 29th, 2012


When Fraud Falls on Deaf Ears, Can You Blow the Whistle?

By G. John Verhovshek, MA, CPC

In the spring of 2003, Columbia/HCA agreed to pay $631 million in civil penalties and damages for filing false claims to Medicare, along with an additional $250 million to resolve overpayment issues. Several years earlier, in late 2000, Columbia/HCA pled guilty to related criminal charges, for which the company paid $840 million in criminal fines, civil restitution, and penalties. In total, the largest and lengthiest health care fraud investigation in the nation’s history netted a return of nearly $1.7 billion for the federal government, and caused a huge shakeup at one of the country’s largest health care conglomerates.

A major player in the drama was John W. Schilling, an otherwise unassuming accountant who had served as Columbia’s Southwest Florida Medicare reimbursement supervisor during the mid-1990s. Schilling uncovered major problems in the company’s cost reporting, which lead to windfall payments from Medicare. Repeated attempts to correct the problems through the proper chain of command produced no results, and Schilling realized to his dismay that his superiors seemed to be acting purposefully to perpetrate the errors.

Feeling that his personal ethics and responsibility as a certified professional accountant (CPA) were at odds with his employer’s expectation to “look the other way,” and failing to convince his superiors to do the right thing, Schilling made the difficult decision to become a whistleblower and reported Columbia’s accounting irregularities to federal authorities. For much of the decade that followed, Schilling was embroiled in the resulting investigation, serving as an FBI informant, testifying on behalf of the Justice Department, and coming under scrutiny himself.

Schilling currently is a partner with EthicSolutions LLC, a consulting firm that specializes in providing confidential direction and advice to whistleblowers and potential whistleblowers, and assists law firms and the federal government with civil and criminal fraud cases. Schilling wrote about his role in the Columbia/HCA case in Undercover: How I went from Company Man to FBI Spy—and Exposed the Worst Healthcare Fraud in U.S. History. He agreed to share some of his experiences, and how they are relevant to coders in the medical environment, with Coding Edge.

Coding Edge (CE): You began working in Columbia’s Fort Myers regional office in 1993, overseeing Medicare cost report filings and coordinating audits with the fiscal intermediary. At what point did you recognize irregularities with Columbia’s accounting?

Schilling: About six months after I started, I had to address how interest expense was handled at one of my hospitals, Fawcett Memorial. Interest expense could be classified either to operating or capital outlays. By over-representing the portion of costs allotted for capital purposes, the hospital received higher reimbursement from Medicare. That is, costs were inflated by including non-reimbursable expenses, and as a result the hospital had received Medicare payments to which it technically was not entitled.

When I began reviewing other reserve issues, aside from the interest issue, I realized many of them were suspicious. Being new, however, I initially assumed—and was told repeatedly—that this was the “normal” course of business.

CE: When you knew for sure that there were problems, how did you handle it? Did you notify superiors or take steps to address the irregularities?

Schilling: Shortly after I noticed the improper cost allocation and brought it to my boss’s attention, I was invited to a meeting with three company executives, including my immediate supervisor, in which this “Fawcett Interest Issue” was discussed. Although it was characterized as a legitimate accounting mistake, it had led to windfall payments for Fawcett Memorial. At the meeting, there was open discussion of how the mistake could be hidden, so those payments would not have to be repaid. I knew then something wasn’t right.

A new manager came into place, reviewed the same reserve documents I had, and likewise concluded many of the reserves were improper if not fraudulent. My new manager and I expressed our concern to upper management, both separately and together. I also wrote memos and provided documentation that went to the director and assistant vice president of our department, showing them a number of reserves I believed to be improper. But nothing happened. Six months later, new management above my manager and me reviewed the issues, and indicated they were not going to reimburse Medicare retroactively for any overpayments. They felt they had no responsibility to self-report, and if the government didn’t discover the error, it wasn’t a problem.

CE: What did you think when those you were reporting to ignored or even seemed to encourage the practices you knew to be inappropriate? What made you decide, finally, to become a whistleblower?

Schilling: I felt self-doubt and frustration, but also thought I might be over-reacting. Very few people within the company seemed concerned with the reserve issues, and it seemed to be normal practice within the industry. On the other hand, I knew what was being done was unethical, if not illegal. And I was frightened. I became concerned that if I went along with these practices, I may be jeopardizing my CPA license, and possibly even facing jail time. After months of debate, I knew I couldn’t just look the other way. I had to do something.

CE: Acting as a whistleblower was not as easy as just telling your story. You were deeply involved in the case for nearly a decade. Did you doubt your decision?

Schilling: I often doubted that I was doing the right thing, or if it was worth the effort. I was intimidated. I had been told “jobs could be lost” if anyone found out about the costly accounting errors. I feared for my own job and reputation. The prospect of physical harm remained in the back of my mind. I uprooted my family, and accepted a job in the public sector at 25-35 percent less pay than I had been making, at a time that I was the sole wage earner. I spent hundreds of hours away from my wife and children each year, in meetings with attorneys and government prosecutors, educating them on the issues, reviewing documents, and preparing for trial. As the criminal trial approached, I had renewed doubts. My decision could send people to jail—people I had worked with and known personally. The case was under seal for years: I wasn’t allowed to discuss it with anyone—even my spouse. I had to distance myself and withhold the truth from family and friends and co-workers. It put a strain on every relationship in my life.

Overall, I’d say it was quite an emotional roller coaster.

CE: The Columbia/HCA case ended with a huge settlement for the government. As a whistleblower, or qui tam relator, you shared in that settlement. How was it decided what your share should be?

Schilling: One would think the government would have an objective process to determine a whistleblower’s reward, but they don’t. Even if you are a team player up to the settlement, you will be forced to battle those with whom you worked side-by-side to obtain your settlement. Even though the law stipulates the relator is entitled to 15-25 percent, the Justice Department is reluctant to reward more than the minimum. The average is 17 percent. You must engage in a negotiation to prove your worth. It becomes a battle with the Justice Department to argue how instrumental you, as the whistleblower, were in obtaining the settlement. Being a whistleblower isn’t an automatic payday. It’s a challenge at every step. If your motive as a whistleblower is solely money or revenge, or if you haven’t got your facts and evidence in line, you’ll not likely get anywhere.

CE: The problems you saw at Columbia revolved around cost reporting and accounting issues, not coding. Does your experience apply to coders?

Schilling: Absolutely! Coders, like accountants, are obligated to properly adhere to Medicare rules and regulations. Whether it’s bookkeeping or coding claims, everyone on the reimbursement team has a responsibility. And, a certified professional coder (CPC®) agrees to abide by a code of ethics, just as a CPA does.

CE: Columbia/HCA was a large, multi-facility company. Are compliance issues as big a risk at small facilities, or the single-provider office? Are payers or government regulators really interested in the little guys? 

Schilling: Yes. The government is interested in anyone committing fraud, whether big or little. From a practical perspective, the government has limited resources and can’t police compliance in all health care providers all over the country. As a result, they try to influence providers to self-report and police themselves. Their interest in the big fish is because there is the potential for larger settlements, and there is a much better chance there will be national publicity. This national publicity serves as a potential deterrent for others who either already are committing fraud or contemplating committing fraud.

But, compliance issues actually may be a bigger risk at smaller, single-provider offices because smaller entities do not have the financial resources to hire trained, experienced compliance professionals. They are more likely to rely on individuals who wear many hats—with compliance being a low priority. With increasing scrutiny of health care costs by payers, government, and consumers, compliance crackdowns will continue to trickle down to smaller and smaller providers.

CE: If I’m a coder in a facility or office, and I notice what I believe to be compliance or coding risks, what would you advise I do?

Schilling: Double check yourself. Review the facts and review the Medicare regulations to help you determine compliance. If you determine what you’re reviewing is non-compliant, you need to start internally. The coder should document the facts and evidence believed to be in violation, and report this to either a superior or the compliance officer, depending on internal protocols. It is imperative for the facts and evidence to be tangible and reported in a way that shows exactly why there is a potential violation—for instance, what regulation is in violation, and how and why it is being violated.

If repeated attempts to correct the issue fail or fall on deaf ears and the practice or facility refuses to correct the problem in spite of clear evidence that it exists, then reporting a violation in an attempt to force compliance is an option. As a partner at EthicSolutions LLC, I help provide confidential direction and advice to potential whistleblowers, and assist attorneys and government prosecutors in civil and criminal fraud cases. One of our current clients is a coder; unfortunately, I cannot discuss anything about this case because it is under a court seal.

There are places where you can get advice on how to proceed. The first step, however, always is to arrange your facts and to attempt to correct the problem internally.

CE: What about preventing compliance risks and improper coding: What influence can coders have, and do you see their role as expanding or contracting in the years ahead?

Schilling: Coders should be proactive in reporting areas that are a potential problem. Doing so will result in a culture change within the organization where compliance is continuously being discussed and reported. To keep compliance an active topic for ongoing discussion, coding compliance should be made part of the agenda of all coding department meetings, or at least on a monthly basis in meetings exclusively devoted to coding compliance. This proactive approach will result in coding compliance being part of the organization’s culture that could serve to prevent government intervention. Or, if there is government intervention for whatever reason, the government may be more lenient in dealing with the organization should they discover an area of non-compliance. Coders also should be advocates for self-reporting to the government should problems be discovered. This will serve the organizational well both short and long term.

Coders can have a significant influence on their organization’s compliance program to benefit the organization and the professional status of coders. 

G. John Verhovshek, MA, CPC, is AAPC’s
director of clinical coding communications.

May 1st, 2010

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