Confirm carrier’s coding advice

To protect itself, a practice should document all written and oral requests and responses.

Issue: March 1, 2004

ByJeffrey S. Peters, JD

Issue

There is a difference of opinion within a large ophthalmic practice regarding a coding question, and the practice administrator brings the question to the compliance officer. The compliance officer believes that the practice codes the service appropriately but wants to make certain of that. Accordingly, the compliance officer contacts the carrier and asks the question. Over the phone, the carrier representative confirms that the practice’s current understanding of the coding criteria is correct. The compliance officer calls the practice administrator and tells him to continue as before, as the carrier has confirmed the practice’s current use of the code.

Is telephone advice from the carrier adequate to protect practice?

At first glance, the administrator and compliance officer have done everything correctly to protect the practice. Uncertain about a compliance issue, the practice contacted the carrier and confirmed the actions. One would expect this to ensure that (1) the practice is acting on correct guidance, and (2) if the advice were incorrect, the practice’s reliance on the carrier would protect the practice if enforcement authorities question the practice’s policies or billings. Unfortunately, neither expectation is necessarily the case. Because carriers do not always interpret the Medicare requirements correctly or the same as CMS, there is no guarantee that the carrier’s advice is correct.

There are several things a practice can do to minimize its exposure in such cases, and the key is documentation. Appropriate documentation will help establish that the practice’s reliance on the carrier’s advice was reasonable.

In its compliance guidance for physician practices, the OIG recommends that practices document efforts to comply with applicable federal health care program requirements. The OIG suggests that practices document and retain records of requests and any written or oral responses. This step is extremely important if a practice intends to rely on that response to guide it in future decisions, actions or reimbursement requests. A written inquiry with a written response is preferred and should be obtained whenever possible.

If written confirmation is not possible, the practice should take steps to protect itself. The OIG suggests that the practice maintain a log of oral inquiries between the practice and carrier representatives. The log should include the date of the call, the phone number called, the first and last name of the carrier representative, the question asked and the answer, written down as close to verbatim as possible. In addition, the practice should write a letter to the carrier that states the oral advice received and the practice’s intention to rely on the advice. The letter should request that the carrier advise the practice if the practice’s understanding is incorrect. Such documentation should help protect the practice should the carrier representative’s oral advice turn out to be incorrect.