Viewpoint: Is downcoding on the rise?

December 5, 2008

Downcoding, whether by audit or during routine claims processing, could be on the rise - particularly for practices with electronic health records, which are able to code for higher levels of service with relative ease.

The words tumble so effortlessly off the tongue of Zoraida Rivera-Hidalgo, MD, you can't help but think she's relishing this latest tussle just a little bit.

Then again, when's the last time you enjoyed an imminent threat to your livelihood?

"You're talking to a self-made fighter," she says with steely pride, 45 minutes into a conversation that had already proven her claim some 44 minutes earlier. "I do not understand can't do. I do not understand failure."

"It's like a full-time job, being the HMO cop," Rivera-Hidalgo says. "Let me see how they're sticking it to me today. You just have to be very vigilant, because they always find another way to withhold money."

In August, one of them came calling with news of a random audit for which she was asked to pull 40 patient charts. A reviewer set up camp in Rivera-Hidalgo's office and, without asking a single question, the doctor says, downcoded 38 charts: 9's became 7's, 5's became 3's. The HMO took $951.82 for the difference.

Rivera-Hidalgo spent a week combing through every record herself. "My charts are very methodical, because I'm a good obsessive-compulsive," she says. "Everything is in its place, but you have to look in there to find it. We explained to them that their reviewer did not look."

The HMO claimed that Rivera-Hidalgo waited too long to file an appeal, she says, but then it reversed its decision and agreed to return the $951.82. Then it reversed course again, opting not to return the money. And then it requested 42 additional charts.

Rivera-Hidalgo's downcoding headaches may be far from over-in fact, brand-new ones are surfacing: After never having been audited in 20 years of medicine, she has drawn the attention of two additional HMOs this autumn alone.

She pauses to count the chart requests from one of them, gasping for air as she winds her way down the list. "Eighty!" she finally blurts. "This list is enough to gag a maggot!" Or a physician, for that matter.

But downcoding, whether by audit or during routine claims processing, could be on the rise-particularly for practices with electronic health records, which are able to code for higher levels of service with relative ease. And for smaller, paper-based practices such as Rivera-Hidalgo's, the demands of time and resources can be crippling. Add to that annual revisions in coding, as well as ICD-10 lurking on the horizon, and the outlook might seem nothing short of maggot-gagging.

"There's a saying in Spanish," says Rivera-Hidalgo: "Lo malo se pega-'bad things are contagious.' I don't believe these things are just a coincidence. I believe it's a very cost-effective measure to have software that spits out downcodes and to harass physicians, who are known to be wimps."

Those are her words, not ours. But the message is clear that staying up-to-date on coding and claims-processing changes is paramount to running a successful practice. In "Is your practice ready for 2009 coding changes?", coding specialist Virginia Martin shares her insight on key changes for 2009. In our Practice Management Q&A, we assist a provider, like Rivera-Hidalgo, who has been accused of overcoding. We also invite you to visit our web poll at http://www.memag.com/webpoll, where you can weigh in on your own downcoding experiences.

As for Rivera-Hidalgo? She's now considering once-unthinkable cuts to her five-person staff-perhaps even shutting down. But after practicing medicine for 20 years, she knows that scratching for reimbursements is part of the game.

"You have to do your job, then you have to do a second job," she says. "It's called recovering what you're worth."

Erich BurnettEditor-in-Chief Send your feedback to eburnett@advanstar.com
.