Question about medical coding:
Have you heard of a scenario in which the attending physician/health care specialist is deliberately vague about a diagnosis because to be more specific (and accurate) in coding would require a new protocol and more troublesome paperwork?
I'm an insurance fraud investigator and have done quite a number of provider fraud cases. On pretty much any Health Insurance Claim form, there are two sets of codes:
1. The diagnostic code (as discussed in this article) which is drawn from the ICD-9 (and now ICD-10). "ICD" stands for International Classification of Diseases, and is established by the World Health Organization.
2. The procedural code or "CPT code" which is the Current Procedural Terminology established by the AMA.
In short, the first code establishes the provider's diagnosis of what the problem is, and the second is the procedure rendered to treat it. A quick example would be a diagnosis of, "laceration," and a procedure of, "sutures." In theory and generally in practice, the procedure should be directly relevant to the diagnosis.
When providers want to play fast and loose, in my experience, it is easier to fudge with the procedure and not the diagnosis. The diagnosis is something that can be relatively easily and objectively confirmed or denied (with some ambiguous exceptions like fibromyalgia and some other soft tissue injuries). The procedural code is what generates the billing and there is more room for manipulation. Whether or not a procedure is appropriate or not becomes a more subjective matter of medical opinion.
Two relatively common scams are known as "upcoding," and, "unbundling." Upcoding is billing for a more extensive or complex procedure than was actually performed. For example, a new patient visit/exam should require more of a physician's time than a routine return visit since the physician will want to collect and review the new patient's full medical history and conduct a comprehensive examination. Sometimes physicians will bill for a more extensive exam than was actually required or performed. "Unbundling," is when there are specific codes for more elaborate procedures that may involve multiple lesser procedures. For example there is a specific code for stitches/sutures. If somebody comes into an ER or doctor's office with a gash that needs five stitches to close, the doctor will do the stitches and bill for the suturing. Virtually all invasive surgeries will mandate sutures to close as part of the surgical procedure, and the codes for those surgeries are supposed to include the closing sutures as part of the surgery, but some physicians or their coders will "unbundle," and bill the code not just for the surgery, but bill the separate code for sutures as well. It would be something akin to buying a car, 'as is' off the showroom floor, and then having the dealership bill you for the car with an extra charge for the tires.
—— Have you heard of a scenario in which the attending physician/health care specialist is deliberately vague about a diagnosis because to be more specific (and accurate) in coding would require a new protocol and more troublesome paperwork? ——
Or a doctor prescribing drugs for off- label use?
Inconceivable!