Medical Records, Insurance Billing and Coding Guidelines
[Reflections on the New Reality]
By Patricia A. Trites
It’s like a game: Get the doctor to add the word “sepsis” to the chart as opposed to “urinary tract infection,” and the hospital can bill for a higher-paying DRG. Or, prompt the doctor to write down “acute respiratory failure”, instead of “chronic obstructive pulmonary disease exacerbation,” and the hospital can once again charge for a more lucrative DRG – Report on Medicare Compliance
Physicians of all persuasions are having trouble adjusting to the radically new use of medical records in the present era of managed care and new reviews of billing practices, like the Medicare Recovery Audit Contractor [RAC] hospital initiatives [Diversified Collection Services of Livermore, CA; CGI Technologies and Solutions of Fairfax, VA; Connolly Consulting Assoc. of Wilton, CT, and Health Data Insights of Las Vegas].
And, doctors worry this “bounty hunter” approach – the second for CMS after medical practice audits – will create a bias to focus only on collecting government overpayments,
So, more than ever, inadequately documented medical chart can mean civil and criminal liability to the sloppy and/or unwary practitioner. Medical records were previously used to aid in the quality of medical care. Now they are also the basis for payment for services, not as a record or reflection of the care that was actually provided, but as a separate justification for billing. The lack of appropriate documentation now no longer threatens just non-payment for services but risks civil money penalties and criminal charges.
More here: BOOK ORDERS [Pre-Release]: http://www.springerpub.com/shoppingcart
Dictionary of Health Insurance and Managed Care: http://www.springerpub.com/prod.aspx?prod_id=49944