1. PRESENTATION ON CODING COMPLIANCE ISSUES
February 7, 2002
Andrew Ruskin
Vinson & Elkins, L.L.P.
Washington, D.C.

2. OIG Initiatives Involving Coding
Hospitals
Payments to acute care prospective payment system hospitals.
Outpatient prospective payment system.
Home Health Agencies
Coding of home health resource groups.
Physicians
1. Physician evaluation and management codes.

3. OIG Compliance Program Guidances
Hospitals
Cautions against:
Upcoding.
Failing to maintain documentation supporting the claim.
Failing to use the most recent coding manuals issued by the AMA and CMS.
Billing for laboratory services that are either improperly coded or are coded by someone other than qualified personnel.

4. OIG Compliance Program Guidances (cont.)
Nursing Homes
Cautions against:
Providing misleading data on the Minimum Data Set (MDS) instrument.
Failing to maintain sufficient documentation to support the diagnosis.

5. OIG Compliance Program Guidances (cont.)
Physician Practices
Cautions against:
Failure to use proper modifiers.
Clustering.
Upcoding.
Advises to conduct self-audits to determine if coding is being done accurately and in accordance with documentation.

6. OIG Compliance Program Guidances (cont.)
Third Party Billing Companies
Cautions against:
Percentage fee arrangements.
Using faulty or outdated software.
“Assumption” coding.

7. OIG Compliance Program Guidances (cont.)
Third Party Billing Companies (cont.)
Recommends that documentation include:
a. Reason for patient encounter.
b. Appropriate history and evaluation.
c. Documentation of all services.
d. Documentation of reasons for the services.
e. An ongoing assessment of the patient’s condition.
f. Information on the patient’s progress and treatment outcome.

8. OIG Compliance Program Guidances (cont.)
g. Treatment plan.
h. Plan of care, including services furnished by other practitioners.
i. Changes in the treatment plan.
j. Abnormal test results.
Identification of relevant health risk factors.
Compliance with E&M coding documentation standards.
Dates and authentications on medical records.
n. Prescriptions.

9. Self-Auditing for Coding Compliance
Structure
Sample size – do you need a statistical sample?
Size of team and its members – do you include counsel? Outside consultants?
Scope of audit – how many criteria are you testing?

10. Self-Auditing for Coding Compliance (cont.)
Execution
Modifications and expansion may be necessary.
Discretion should be maintained.
Follow-up
Repayment.
How much?
To whom?
Education of staff.

11. Gather information from other organizations.
Managing an OIG Audit
Know the law.
Know yourself.
Gather information from other organizations.
Negotiate scope and timing.
Manage your employees.
Appoint a liaison.
Seek to review the final determination.