ProPublica has analyzed data from CMS that shows that the practice of upcoding, which CMS defines as overbilling, remains an issue some doctors are still billing Medicare for the most expensive office visits most of the time.

The services provided must relate to the medical condition(s) present and treated, documented, and then billed.  Any physician can come under scrutiny, and the defense is through and complete documentation that supports the care rendered, and diagnoses requiring treatment at the visit that justify the level of service.

And in a world of high politics, there is no such thing as up-coding.  It is fraud.  The physician is considered guilty based on the code billed, and the medical record that does not support that code.  The public clamor for a villain for increasing healthcare costs very quickly includes the physician that up codes.  There are good headlines to be had in “your tax dollars at work” as funds are recovered.

While the Trump administration is rolling back regulations, not so when it comes to fraud identification.  $70 million more has been added to these efforts at a time when the rest of the Department of Health and Human Services is taking significant hits to its budget. Data analysis is being increasingly fine-tuned to identify physicians whose practice patterns deviate from the “norm”, as to invite scrutiny.

For the physician, knowing coding and documentation continues to be critical. Leaving coding to your biller means leaving not only your income to them but also what could be a risk to your license.

Step one in looking at your own billing and coding should be to compare your pattern to others of the same specialty. Medicare and your specialty society have the available analysis of physician coding patterns for you to use.  Use them.  This will give you an indication if your pattern makes you an outlier, inviting scrutiny.

Such comparative information can also identify if you have fallen victim to potentially under coding as well.  In response to well-published challenges and recoveries against physicians, many have sought to reduce their risk of being an outlier by intentionally under coding.  This means leaving money, your money, behind.  Some studies show that physicians are leaving an average of over $25000 a year behind having been cowered into under-coding.

While you make think you know coding, and documentation, it is an area that you and your practice should invest in.

Reduce your risk of bad receivables

Have your EHR provide a report of your coding pattern. Compare it to the national norms form Medicare and your professional society. Then get educated.  It is worth an investment of $4000-$6000 for a certified professional coder to come into your office, review your charts, your documentation and then, based on that review show you how to code better, stronger, and then bill with a greater sense of surety against challenge.

This “self-audit” of your coding and documentation should not be a one-time thing.  It is worth doing the same review annually against the coding patterns of your specialty, and every few years having the coding specialist do an assessment. Being able to code with confidence is a great relief and often a good generator of funds that have been well earned by your efforts.

The Office of Inspector General has long warned that doctors are responsible for billing Medicare at appropriate levels for office visits.

For example, a New York anesthesiologist found themselves paying back nearly $2 million in 2017 for improper billing, billing for services that the billing code describes as 16-minutes of face time with the patient when such was not occurring.

For some physicians, a small percentage, consistently bill at higher levels for office visits, billing Medicare 90% of the time for the most complicated and expensive office visits. Level 5.

Making the argument that a physician’s patients are always the sickest is only true if there is evidence to support the clinical need for the high level of services rendered, as well as diagnoses that support that severity of illness.  Billing for level 5 visits, when only 15 minutes is scheduled for a patient visit is clearly going to demolish this argument.

Over-reliance on checkboxes for documentation in the physicians EHR may lead to the automatic assignment of higher billing codes that are supported by the actual patient need and services rendered.  The same is true of physicians that fall into the trap of cutting and pasting medical notes rather than writing them for each patient.  Improving audit technology is readily identifying the plagiarism across medical records, making it a shortcut that can come back and haunt.

Now physicians should not be cowered into shortchanging themselves by down coding their services.  The response should be to gain a proper foundation in coding and documentation specific for your specialty and then document properly diagnoses and procedures to legitimately maximize your revenue.


Alex Tate is a Healthcare IT Researcher and writer at CureMD who focus various engaging and informative topics related to the health IT industry. He loves to research and write about topics such as Affordable Care Act, EHR, revenue cycle management, privacy and security of patient health data.