Pattern Billing

Pattern billing is the billing of a single code creating a patterning effect. For example, if practices decide that every subsequent hospital visits should be level three (99233), this would be considered pattern billing. Pattern billing can also be found in diagnosis coding, most commonly where practices utilize pre-printed diagnosis codes on their patient encounter forms (Superbills). In problematic cases, physicians may only choose diagnoses that are listed on their forms, and may not "write-in" the more definitive diagnosis codes applicable to the patient visits. For example, practices might pre-print the abdominal pain diagnosis code of 789.00 on their Superbills. The placement of the 5th zero establishes the location of the pain, with zero defining the location as unspecified. By using this method the practices would be inappropriately denoting that every diagnosis of abdominal pain is in an unspecified site.

Pattern billing can largely be avoided by carefully designing practices’ Superbills, by limiting the use of pre-printed codes and through appropriate physician and staff education. For example, the issue described above could easily be corrected by simply printing 789.0 __. When the physicians or physician extenders see the line for the 5th digit, they would then know that they must identify the location of the pain for the billing staff. If the physicians indicate the location by writing it by the code, the billing and coding staff could then assign the correct number to it before submission of the claim.

Duplicate Billing

The collection and follow-up of accounts receivable presents the practice with another dilemma. When claims are not timely paid some physician practices will automatically re-submit those claims without performing any prior follow-up in attempts to identify the reasons behind the non-payments. Where the non-paid claims are still active with the payers, this practice can result in two (or more) identical claims for payment. To avoid this result, practices should consistently contact the applicable payers to confirm and to identify the reason for the non-payment, prior to re-submitting any claims. Billing personnel should be trained to consistently follow this practice, which should be part of physicians’ written billing procedures.

Billing for Services/Procedures Not Performed

Billing for services that were not performed is an obvious violation of federal and state law, and can occur more easily than many physicians realize. For example, a patient is seen in the office setting. The physician selects the level of office visit and an EKG on the Superbill. Before the physician is able to speak to his or her staff about the pending EKG, he or she is called to the phone. The staff, unaware that the physician would like an EKG on the patient, sends the patient home. The practice’s unknowing biller then enters both the office visit and the EKG into the computer, providing an inaccurate claim to the payer. To avoid this problem, practices’ Superbills should require physician certification that the individual services described on the form have been completed, as they are completed. Providing this information can act as a check for the billing department, who would not bill unless the individual services are specifically certified as completed. In the alternative, internal procedures could prohibit completion of the Superbill until all services marked thereon are completed.

Code Steering

Code steering is disregarding certain levels of evaluation and management (E&M) codes within particular categories of procedure or diagnosis codes. As with pattern billing, the use of inappropriately drafted Superbills is often at the heart of this problem. For example, physicians might list all the levels of E&M for new office patients (99201-99205) and for established office patients (99211-99215) on their Superbills, but only one level of outpatient consultations (99244). This creates a strong tendency for the physicians or physician extenders to use that single level of outpatient consultation, no matter the actual appropriate level. To avoid these problems practices should review their Superbills to be sure that they list all of the available levels within the individual categories. Additionally, practices should implement policies that prohibit code limitations on their Superbills and should review their Superbills annually to ensure their continued accuracy and compliance.

Prioritizing Diagnosis Codes

All diagnosis codes must be accurately prioritized. The failure to do so can cost practices reimbursement and in some cases can create significant liability. For example, an office recently visited allowed the receptionist to choose the diagnosis code when inputting the data into the computer system. When the patient had multiple diagnoses, the receptionist would identify the ranking order of diagnoses by starting at the left side of the form and working to the right. Using this method, the secondary diagnosis could easily be listed as primary simply because it was in the first column of the form, resulting in an inaccurate claim for reimbursement. To avoid these problems, there should be clear policies prohibiting pre-prioritizing of codes. Providers performing the services should be required to personally rank the codes in numerical order, as opposed to checking them off or circling them on a form. Where the providers have not prioritized the codes, billing should be prohibited until the providers personally prioritize the codes.

Medical Record Documentation

About half of all allegations of inaccurate billing arise from insufficient documentation in the medical record, resulting in denials based upon lack of medical necessity or due to alleged upcoding. Two particular problems frequently cited include the review of patients’ medical and personal histories, and failures to provide adequate supporting documentation for diagnoses and procedures. To help to avoid problems associated with patient history forms, physicians should be sure to initial or sign the forms themselves. These forms can then simplify physicians’ documentation by allowing the physicians to insert references such as: "I have reviewed the patient history form regarding their past, family and social history and find nothing remarkable" into the corresponding medical records. References for subsequent patient visits might read: "The history form has been reviewed and is unchanged," or "The history form has been reviewed and the following change has been made..." If the forms are not properly acknowledged, however, the information contained on them cannot be used as part of the physicians’ documentation.

For documentations supporting diagnoses or procedures, physicians first must ensure that the services provided are consistent with the symptoms of the patient and that they satisfy generally accepted medical standards. Thereafter, physicians must ensure that their documentation is adequate for coding and quality assurance purposes. Part of this effort requires that physicians understand and remain current on the relevant documentation standards. Physicians should strongly consider attend coding and documentation workshops on an annual basis to establish and to refresh their skills in documentation, and to master changing requirements.

An inexpensive but often effective mechanism that physicians should consider is checking each others’ medical record documentation and coding on a regular basis (perhaps monthly) prior to submitting same for billing. Particular attention should focus on practices’ new physicians and physician extenders, with more frequent and more intense reviews. By checking each others’ records and coding physicians can share their knowledge and skills while working together to ensure that their practices’ documentation and coding is of sufficient quality.

Discounting Services or Procedures

Improperly discounting services can result in serious negative consequences. Under CMS’ current policies, fees or portions of fees that are routinely waived should result in the reduction of providers’ corresponding "allowable charges;" failure to do so would allegedly violate the federal False Claims Act because providers would be mis-stating their actual charges. For services provided to government program beneficiaries, CMS has also posited that providers could be liable under the federal Civil Monetary Penalties Law for providing illegal financial inducements, and in the case of professional courtesy, under federal Anti-kickback Statute for illegally inducing physician-recipient referrals. Individual state’s laws and private insurance contracts also frequently limit or prohibit certain types of discounts or waivers.

To avoid these problems providers should carefully review their state’s standards, as well as their insurance contracts, in relation to discounts and waivers. Moreover, providers should refrain from waiving fees or portions of fees except where those waivers are based upon well-documented findings of individual financial hardship, or where the waivers occur after reasonable collection efforts. To facilitate this process, providers should establish and uniformly apply legally acceptable, clear financial hardship standards, along with information gathering and collection procedures, in order to facilitate the clear, consistent and legal application of this process. By practices’ partners or Boards of Directors passing formal policies on discounts and waivers, individual physicians can avoid some of the pressure that exists to provide professional courtesy to other professionals or to friends.

By developing and implementing the above policies, procedures and practices, physicians can improve their efforts to overcome the serious challenges inherent claims development, submission and reimbursement, and can help to ensure the financial well being of their practices.