Avoid the Red: Understand Your Liability as a Coder

Why This Topic Matters

Coding decisions can create legal, financial, and patient-relations consequences. Understanding the general areas of liability helps coding professionals recognize when to escalate concerns and maintain compliant documentation and reporting practices.

Article Sections

1. Avoid What Smells Like Fraud

   Discusses general fraud-and-abuse concerns in coding, including how compliance issues may be viewed by government payers and regulators. It introduces broad categories of risky billing behavior and the importance of recognizing patterns of improper activity.

2. Unbundling

   Covers the topic of unbundling and the use of Medicare National Correct Coding Initiative resources and edit concepts. It also references related edit concepts involving same-provider, same-beneficiary, same-date-of-service reporting.

3. Bundling

   Describes bundling as a compliance risk and places it in the broader context of coding and reimbursement concerns. The section addresses general concerns about combining services inappropriately.

4. Upcoding

   Addresses the risk of reporting more extensive or more expensive services than were actually furnished. It explains this issue as part of the broader discussion of fraudulent or abusive coding behavior.

5. Don't Anger Patients

   Shifts to patient-record and liability concerns, including the effect of diagnosis coding on patients and potential disputes. It also touches on how coding choices can create documentation and legal concerns when diagnoses are uncertain.