Navigating the Complexities of Nephrology Coding and Billing

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Over- and under-documentation are equally considered fraudulent, and may increase audit risk, so it is essential to get coding and billing right the first time.
Over- and under-documentation are equally considered fraudulent, and may increase audit risk, so it is essential to get coding and billing right the first time.

With the growing body of regulations today, nephrology coding has become more complex. Practices must navigate not only a new level of required specificity but also additional requirements from payers. Needless to say, it can be daunting to stay abreast of all of the guidelines for CPT, E&M, and ICD-10 coding — all while continuing to provide quality care for patients. Periodic reviews and education, however, can save you and your practice time, resources, and money.

Coding and billing mistakes carry stiff penalties. The Centers for Medicare and Medicaid Services places a significant focus on fraud and abuse regulations regarding the submission of physician billing, coding, and documentation. Over- and under-documentation are equally considered fraudulent, and may increase your practice's risk of an audit, so it is essential to get coding and billing right the first time.

Coding reviews can help nephrologists assess the accuracy and completeness of the documentation of services provided as well as to determine if that documentation supports the claims ultimately submitted for payment. It is critical to the success of a nephrology practice to be accurately reimbursed for services provided.

One might think that coding training is just for new physicians, but coding standards and guidelines have changed so much over the past 20 years that experience does not necessarily lead to more accurate coding. In fact, we analyzed the coding accuracy of nephrologists who have used our coding training and education, reviewing the physician's years of experience, coding accuracy and risk. The coding accuracy was focused on new and established office visits, as well as initial and subsequent hospital visits. The review focused on “at risk” codes that were deemed to be an audit risk due to the frequency of use by the nephrologist, and codes that are being monitored by auditors. We analyzed how each physician coded compared with the rest of the practice and identified a specific physician who was at audit risk, or would place the practice as a whole at audit risk.

In our evaluation of 97 physicians, we found that physicians who were newer to nephrology practice tended to over-document and under-code, whereas physicians who had more than 5 years of experience under-documented and over-coded.

Following the initial coding review, we provided education to each physician individually discussing and highlighting where their errors occurred either through documentation and/or evaluation and management selection. After their initial coding review and education, we followed up at 30, 60, 90, or 120 days, depending on how the physician scored.

We found that physicians who were presented with coding review results and applicable education all showed improvement in their coding accuracy. Improvement declined after 6 months, however, if coding reviews and education did not continue.

The good news is that nephrologists who receive continuous reviews, monitoring, and education on their coding accuracy and appropriate documentation maintain a higher coding accuracy profile than those without such monitoring.

These findings suggest that one-time reviews and trainings are insufficient to maintain coding accuracy and both new and experienced nephrologists benefit from continuous education.

History tells us that reimbursement and regulations will only continue to change, and providers will continue to face increased scrutiny from Medicare and other payers. The best way to improve business practices and minimize a practice's risk of an audit is to implement a structured coding review and ongoing education. Depending on the practice, this can be done different ways. Some practices have the resources to handle this function internally. Others may consider the complexity of regulations and the day-to-day demands of running a practice and decide to engage an independent expert who can objectively review performance and provide the necessary ongoing education. Either way, a continuous focus on accuracy and improvement is essential for optimizing appropriate reimbursement and mitigating the risk of penalties.

Robert Provenzano, MD, FACP, FACN, is Chief Medical Officer, and Suzanne Leathers is a Registered Health Information Technician and a Certified ICD 10 CM/PCS Trainer and Coding Review Supervisor, for Nephrology Practice Solutions at DaVita Inc.

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