Judith Waltz Discusses Medical Coding Compliance Challenges

Foley & Lardner LLP partner Judith Waltz discussed Evaluation & Management (E/M) level medical coding for office/outpatient visits in the Report on Medicare Compliance, “Health System Settles Case Over E/M Levels, Modifier 25; Diagnoses Are Key to Downcoding,” published by the Health Care Compliance Association.

Waltz explained that there is “virtually no wiggle room with time” in medical coding, though she noted that decisions about levels of service are more fluid with medical decision making.

“If you do coding based on medical decision making, you can make that argument about differences of opinion, but on time you’re dead in the water,” she continued. “Some providers have time-tracking devices, particularly for telehealth calls, and if the time spent did not align with the time claimed, there really isn’t any way around a conclusion of upcoding.”

Waltz also highlighted that higher-level CPT codes “might be slightly easier to defend if you are just one level off,” and that coding variances best serve as educational moments absent a pattern of error, cautioning though that “two levels is typically too far off to support an argument about a limited difference of opinion.”

“Under ICD-10, you can’t just call it a cold,” Waltz added. “You have
to dig in a lot deeper in terms of documentation. And the increased level of specificity may contribute to the complexity level, either higher or lower, of the medical decision making.”