E/M coding and “aiding and abetting”?

Happy Thanksgiving to everyone!!!! I hope you have a great day and safe travels.

This post is a follow up to yesterday's. Suppose you have a physician who is overcoding his or her office visit services. For example, you have a doctor who likes to "lock in" to a specific code, say CPT 99213 for an established patient. You review a sample of medical records to make sure the documentation supports the CPT billed. It doesn't so you attempt to counsel the doctor on proper documentation procedures and provide education on E/M coding.

The physician continues to overcode. So you get an independent consultant to review a sample of the medical records and the consultant determines that the doctor is overcoding office visits. The doctor still doesn't change his or her ways. So now you get a physician to talk with the offending doctor and still no change.

Here are my questions: After identification, counseling, education, and monitoring within the practice by management of the doctor's coding practices, can management be accused of "aiding and abetting" coding fraud? If the physician does not change, has he or she crossed the line from ignorance to intentional criminal fraud? These a definitely things to ponder.

The bottom line is this...........practices must have the courage to terminate a physician in these type of situations if change does not occur. No only can th practice get in trouble since it's the billing agent, individuals can too!

Have questions? I’m here to help.