Note from the Instructor: Beware of internal auditor motivations and erroneous internal reporting policies

By Allen Frady, RN-BSN, CCDS, CCS, CRC

The following is a list of things I have been told to do by auditors and even gotten my personal evaluation score lowered for failing to do:

• Always sequence congestive heart failure above pneumonia and respiratory failure
• Code all induced ventricular tachycardia in the electrophysiology studies lab as a diagnosis
• Code all patients on the vent post-operatively as being in post-operative respiratory failure
• Report a diagnostic catheter as a separate procedure on patients only receiving an endomyocardial biopsies
• Ignore repeated admissions for “cerebral vascular insufficiency” even when there were no apparent indicators or explanation of the admission in the record
• Up-code the evaluation and management levels about one level higher
• Ignore my own years of nursing and clinical knowledge when it came to miscoding a diagnosis because the coding auditor knew better

This is not a comprehensive list by any means. There are many, many more of these examples. I am happy to say that I ignored most of the above advice. Do you want to be promoted based on sleazy behavior or do you want to sleep well at night because you work in an ethical and accurate manner? I choose ethics and accuracy every time, and I sleep like a baby.

Fortunately, most of the above practices have been squashed via Coding Clinic and a couple of them have been in the OIG Work Plan over the years. Be that as it may, new ones have cropped up like whack-a-moles on a bad outing to Chuck E. Cheese. The good news is that both supervisors and auditors (some) are more open to the follies of such activities and reports of potential fraud and abuse are taken more seriously nowadays without the on-the-job repercussions once threatened. Never be afraid to question what you have been told. “Because I said so” is never a good enough reason. Ask to see the clinical reference, the policy, or the guideline.

On the flip side, over precaution where there is a pattern of intentional under billing, under querying, and under reporting due to an irrational fear that doing perfectly legitimate work will somehow get you in trouble is also a very real occurrence. This usually happens as a result of over reliance on older, outdated guidelines which have been superseded, or hear-say from an audit finding which was itself incorrect.

People think if it came from an auditor that it must be correct. Nothing could be further from the truth. I’ve seen a steady volume of mistakes by auditors and “subject matter experts.” No one is infallible. I have been at this for almost 20 years and I still learn something every day. If you suspect your facility falls under the category of “ultra-conservative,” please work to find a happy medium. Both over-caution and over-aggression are technically inaccurate and erroneous strategies.

Editor’s note: Frady is a CDI education specialist for BLR Healthcare in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement- boot-camp-1.