12
COM Outlook . Summer-Fall 2014
HEALTH CARE LEGAL EAGLE
The Importance
of Coding
By Fred Segal, Esq.
While they may not have imagined it, physi-
cians begin to realize very quickly into their
medical career that they have to oversee cer-
tain administrative functions related to their
practice of medicine that are neither fun nor
exciting. Most of these administrative func-
tions, however, are essential for maintaining
a successful physician practice. Carelessness
in the performance of such tasks could subject
a physician to a suspension or loss of his or
her medical license.
Medical coding, for example, is one of the
most important administrative functions a
physician will face. In most instances, the ma-
jority of a physician’s services are reimbursed
by a third party payor, such as an insurance
company or a government-funded program
like Medicare. Medical coding, generally, is
the process taking a physician’s documenta-
tion of the services he or she performs and
matching it to a specific clinical code. This
process is performed by a medical coding
professional, who then creates a
claim
for
payment that is presented to a payor.
Proper coding depends on the medical
professional to assign the appropriate code to
a procedure performed, as well as the physi-
cian to accurately document the procedure
performed. Some of the more common cod-
ing violations are
upcoding
(assigning a code
for a similar but different procedure that pays
a higher reimbursement) and
unbundling
(coding a procedure as a single service when
such procedure should be treated as part of
another bigger procedure).
Inaccurate coding can create numerous
problems for a physician and his or her prac-
tice. If a private payor (e.g., a health insur-
ance provider) finds inaccuracies in the claim
for payment, it may deny payment, and the
physician or his or her practice will have to
Choosing to become a
medical professional
most likely stems from
a desire to help fellow
citizens, save lives, and
make a difference in
the world. When aspir-
ing physicians go to
medical school, more
often than not they
are solely focused on
learning how to physi-
cally practice medi-
cine; that is, consulting
with patients, diag-
nosing illnesses, and
prescribing treatment.
Fred Segal is a health law attorney
in the Miami office of the law firm
Broad and Cassel and is a graduate
of NSU’s Shepard Broad Law Center.
go through the headache of appealing the
insurer’s decision.
In addition, inaccurate or false informa-
tion on a claim for payment to a government
benefits program (e.g., Medicare/Medicaid)
could subject a physician to extremely harsh
penalties. First, the government program
may treat the inaccurate claim as an overpay-
ment and demand a refund of the amounts
received. Also, if it believes it can prove
that a physician intended for a government
payment to be made from a claim that was
falsely coded, the United States Department
of Justice could bring charges against the
physician, which could result in prison time,
or the Office of Inspector General can bring
a lawsuit against the physician and his or her
practice that could result in exorbitant fines.
A wise man once said, “What you put in with
the pen you can’t take out with the sword.”
Everything a physician writes down, or every-
thing that is sent out on his or her behalf, must
be accounted for and be accurate. If not, major
problems could be on the horizon.
