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AHA pushes back on administration's charges on coding

September 25, 2012

The AHA yesterday in a letter to the departments of Health and Human Services and Justice reiterated the hospital field's commitment to combating fraud and abuse and again called for national guidelines for the reporting of hospital emergency department or clinic visits using a framework the association has proposed repeatedly since 2003. The letter was in response to a letter the association received yesterday from the departments, prompted by an article in the New York Times, charging that electronic health records may be used by some hospitals and physicians to increase their Medicare reimbursements through "upcoding" and the "cloning" of records. AHA President and CEO Rich Umbdenstock concurred that the alleged practices should not be tolerated but noted that it is also "critically important to recognize that more accurate documentation and coding does not necessarily equate with fraud." In addition, he cited the complexity of Medicare and Medicaid payment rules and reiterated the association's request for national guidelines for the reporting of ED and clinic visits, a request AHA has made 11 times. Although CMS in 2004 and 2005 stated it would consider national coding guidelines, it has yet to issue a proposal. "What's needed is clearer guidance from [the Centers for Medicare & Medicaid Services], not duplicative audits that divert much needed resources from patient care," he said. "No one questions the need for auditors to identify billing mistakes; but the flood of new auditing programs, such as Recovery Audit Contractors, [Medicare Administrative Contractors] and others, is drowning hospitals with a deluge of redundant audits, unmanageable medical record requests and inappropriate payment denials," he added, noting respondents to AHA's latest RACTrac survey are appealing more than 40% of denials with a success rate of 75%.