Medical school curriculum is heavy in anatomy, physiology, biochemistry, pathology, and clinical rotations or clerkships. There is very little, if any, instruction on proper coding and billing for professional services. The years a physician spends during residency might result in a little training in coding and billing, but typically it is not extensive. After residency, a physician is thrown into the real world of compliance risks associated with coding, billing, and documentation. Some physicians report the rules don’t make sense. Other clinicians report being too busy with patient care to have time to learn billing and coding rules. However, ignoring some common coding and billing risk areas can result in questionable compliance practices, potential audits, and, in some cases, enforcement.
What are some of the most common coding, billing, and documentation compliance risks that physicians face today? There are many, but let’s take a closer look at two common areas: upcoding and misuse of modifiers.
One of the most common coding and billing compliance risks that physicians face is the practice of upcoding. For decades, upcoding has resulted in False Claims Act allegations by the government and whistleblowers, resulting in significant financial settlements, corporate integrity agreements, and internal or external audits.
Upcoding is a practice of submitting a claim with a higher or more extensive medical code when the...
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