Last October, I wrote a column titled “Just Another Phone Call.” This article described the amount of misinformation out there on medical coding and compliance issues being provided by lecturers who tout themselves as experts, but they simply don’t have either the knowledge or the references for the things they proclaim from the podium. I introduced (and hopefully reinforced) four concepts:

  • Establish medical necessity before billing a medical carrier.
  • Chief complaint always drives the encounter.
  • Charge the same fee for the same procedure to everyone without bias.
  • Verify any information you receive from a lecturer before you use it in your practice and put yourself at potential risk.

While I received many compliments on the article, I also received many e-mails and telephone calls from practitioners around the country basically saying that we O.D.s aren’t really at risk for audit problems because we are such a small part of the health care picture. They also said that if fraud is committed but isn’t intentional, then it’s really not such a big deal.

It made me really wonder what goes on in practitioners’ minds on a day-to-day basis when it comes to patient care.

It has always been my position that the patient care comes first, the medical record second, and lastly, the coding comes directly from what is written in the medical record. It amazes me that there are individuals on the podium who continually ignore the basic tenets of medical coding because they only have dollar signs in their eyes as the motivator…

Claim denied with the correct code? No problem—change the code to one that will get you paid.

Office visit denied when billed with a surgical procedure? No problem—use a modifier to skirt the rules to get paid.

Claim denied due to a non-covered diagnosis? No problem—just change the patient’s diagnosis to one that gets you paid.

Avoid Fraud and Abuse
What the heck is going on? Is money the only motivation that we have? Is the basis of all of the clinical testing that we perform driven only by the reimbursements that we have to generate to make the monthly payment?

Maybe people simply don’t want to follow the rules. Maybe they feel that the risk of being caught is acceptable and the penalties won’t be that severe.

This ignorance is frightening to a guy like me who gets called to help defend practitioners when they are audited—because while random audits can’t be prevented from occurring, audits targeting by inappropriate billing procedures certainly can.

To that end, the Office of Inspector General recently published a brand new handbook, “A Roadmap for New Physicians Avoiding Medicare and Medicaid Fraud and Abuse.” It’s specifically aimed at helping practitioners avoid the most major causes of fraud and abuse. I highly recommend downloading and reading this material.

Best of all, it will only cost you a little time. That’s a pretty good value, considering that the price of ignorance can be significantly higher.

Please send your comments to Review's clinical coding committee at

Clinical Coding Committee
John Rumpakis, O.D., M.B.A., Clinical Coding Editor
Joe DeLoach, O.D.
David Mills, O.D., M.B.A.
Laurie Sorrenson, O.D.
Rebecca Wartman, O.D.