Corporate Compliance

Are we liable for an errant coding manual?

Compliance Monitor, September 16, 2005

Q: An employee at my facility has taken it upon herself to put together a coding training manual. This training manual has been printed, bound, and distributed to a multi-specialty practice.

Much of the content is composed of paraphrased guidelines without citing the source for the reader to find the CMS regulation in its entirety.

Our department has raised concerns over what we feel is an inadequate training manual and has sent the manual to two national coding consultants for review. These experts concurred with our staff.

If we were ever audited by the OIG and an investigator were to see this coding manual made by an employee-with her name on the front cover as the author-would we be held liable for not practicing compliant coding? Even though this manual has never been approved by the board, would the entire organization be at risk for fines, or even a corporate integrity agreement for having a misleading training manual?

A:An organization should never permit use of an unauthorized training manual.

By doing so, it becomes a party to any mistakes made by the author of the manual. Such a manual should be withdrawn immediately.

Moreover, some at the organization have demonstrated their concern about the manual by having it reviewed-and that review apparently found the manual inaccurate. Yet the organization has evidently continued to allow its use. In so doing, the organization has become a party to any errors.

If this is the case, prior submitted claims should be reviewed, repayments should be made where they are inaccurate, and (if time permits) new claims should be submitted.

If an organization knows billing errors are being made, and it does not correct them, the organization could be criminally liable for those "errors." Indeed, if an organization does not have a compliance program in place to catch errors, continuous billing errors by "reckless disregard" become false claims. In other words, "knowledge" is not a prerequisite for exposure to penalties and a corporate integrity agreement.

As a side point, in my view, the last thing you want in a training manual is references to regulations, manual provisions, or other CMS documentation. Even experts frequently argue about the meaning of these government documents-and you don't want every employee following his or her own interpretation.

That said, a coding training manual must be accurate and not misrepresent any aspect of the coding process or the medical records and documentation upon which codes are based.

Of course, the scope of "coding training manuals" can vary.

Such manuals can be for single-specialty coding and focus only on the codes derived from the underlying documentation; these are generally straightforward. On the other hand, a manual can be for a multi-specialty practice; this type is much harder to put together accurately. Manuals that deal with various enforcement provisions in addition to coding can become very complex. I suggest recruiting an expert to write your facility's billing manuals.

This week's answer was provided by John Reiss, Esq., partner at Saul Ewing LLP in Philadelphia.

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