PubMed · 10586776
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N Bush, L Cronin. 1998. Ensuring consent is informed.. https://pubmed.ncbi.nlm.nih.gov/10586776/
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The Netherlands have the 'Wet op de Geneeskundige Behandelingsovereenkomst', a law concerning the medical treatment agreement with the patient. Among other things it regulates the duties regarding the keeping and destruction of medical records. A critical evaluation is necessary, because the existing regulation is expected to have a negative effect on patient care and on scientific research. Development of better criteria for destruction of medical records is necessary. Until then, the destruction of medical records should be stopped.
Physicians need to be proficient in their use of CPT codes and ICD-9 codes. They must participate actively and be knowledgeable of their billing process. An organized approach to coding and billing has been suggested by the American Academy of Pediatrics, as outlined in the following box. Physicians are ultimately responsible for any bill submitted in their name. Therefore, close scrutiny of the coding and billing procedures is paramount. Even if mistakes are made in the billing process beyond physicians' input, physicians still may be held responsible. If physicians do their own coding, the bills become more accurate, which can result in higher reimbursement. Physicians also should have a functional compliance plan in place, whether practicing in a large faculty group practice or practicing solo, with the ability to audit the coding and billing process and respond to variances if they are found. By being more involved in the process, physicians can have a more efficient billing system that avoids the potential for fraud and abuse and improves collections.
PURPOSE: To evaluate the accuracy of Current Procedural Terminology (CPT) coding for interventional radiology services when coding is performed by the operating physician. MATERIALS AND METHODS: Coding data for 1,174 interventional radiology encounters in 736 patients were analyzed for appropriate use of CPT codes. Physician operators initially assigned provisional codes. Formal coding for billing purposes was performed at a later date by one of two experienced interventional radiology physician coders. Initial operator coding errors and associated relative value unit (RVU) impact were analyzed. The coding patterns of experienced physician coders were compared with those of the other interventionalists. RESULTS: Only 82% of encounters were initially coded correctly, with a small net tendency toward undercoding. The overall net RVU impact of errors was only -1.2%, with the effects of undercoding outweighing those of overcoding. More complex cases (> or =4 CPT codes) were much more likely to be coded erroneously than less complex cases (24% vs 14%, P <.001). Experienced physician coders committed significantly fewer errors than other physicians (10% vs 25%, P <.001), but there was a similar minimal net RVU impact of errors (-1.1% vs -1.4%, P =.198). CONCLUSION: Although initial physician coding errors for interventional radiology procedures are common, the net RVU impact is minimal. The accuracy of experienced physician coders is significantly higher than that for other interventionalists. Because of the regulatory consequences of coding inaccuracies, practices should establish quality improvement systems to minimize errors and use the skills of experienced individuals in their coding processes.