The 2012 edition of DRG Plus! defines the insurance term gaming as, "Gaining advantage by using improper means to evade the letter or intent of a rule or system." Obviously, gaming isn't something insurance carriers want to see.
Insurance carriers are notorious for violating their own policies and changing rules midstream without notifying policy-holders or providers. They have dozens of dirty little tricks and utilize a variety of lies ranging from little white lies to outlandish fabrications. They are also adept at transferring blame for messes they create to the provider in order to save face with the insured.
Nonetheless, we must avoid stooping to their low levels of character. We have our personal, professional and profession's reputations to protect. Deliberately taking advantage or evading the intent of a system is to be avoided at all costs. This applies to agreements with private, state and federal carriers.
| Examples of Diagnosis Coding Considered Gaming | |
| Procedure | Example |
| Upcoding | Listing every condition as a disc condition using the excuse that the majority of vertebrae are connected to a disc so, a disc is always involved. |
| Downcoding | Listing a true disc condition as subluxation. This situation may have more to do with the doctor's philosophy than the actual diagnosis. (Sorry, while subluxation is a required diagnosis for Medicare, the diagnosis is not taken seriously by carriers.) |
| Unbundling | Listing a cervical sprain with cervicalgia and muscle spasm. Cervicalgia and muscle spasm are assumed as part of the sprain. |
| Build-Ups | Listing spinal sprains for every level along with cervicalgia, lumbalgia, disc disorders, muscle spasm, edema and other diagnosis for the same accident. Even if all of the conditions listed are present, list only the most serious. |
Upcoding
Over the years we have heard questions and comments from doctors regarding which codes pay the best. In other words, "What code(s) can I use the will allow me to treat for the longest period of time?" Obviously, if the doctor is looking to increase the allotted amount of care beyond what they feel the true diagnosis would allow, they will have to increase the severity of the diagnosis. This is upcoding.
The problem here is obvious. In terms of their condition, the patient has what they have and what the doctor's findings can prove they have. If the patient's policy benefits fall short of what will be needed to control or resolve their condition, the doctor cannot assist the patient by listing a more serious condition in order to extend the patient's benefits.
Downcoding
Just as the practitioner must avoid upcoding, the practice of downcoding should also be avoided. Downcoding is assigning a diagnosis of lower severity to a patient's condition. This policy is not as much of a detriment to the carrier as it is to the patient. If the downcoded diagnosis has limited coverage, the patient's benefits may be cut off prematurely. If care continues beyond the point justified by the assigned diagnosis, the carrier may consider the practitioner to be guilty of overutilization.
Unbundling
Listing the signs and symptoms of a condition as individual diagnoses when simply listing the condition itself would suffice is called unbundling. Many spinal conditions produce a variety of signs and symptoms. Those signs and symptoms are part of a complex. In many cases the code for the primary condition is sufficient to cover the overall complex. The individual signs and symptoms do not need to be listed as diagnoses. They are just signs and symptoms, and not necessarily diagnoses by themselves.
Muscle spasm is not a diagnosis, but a symptom. It can be part of the presentation of several diagnoses. The root cause of the spasm is the best diagnostic choice. In some cases, conditions listed as a syndrome may be the best choice, as a syndrome is a compilation of signs and symptoms.
Build-Ups
Build-ups are utilized to make a case seem worse than it truly is. They are related to upcoding and unbundling. The provider must upcode and unbundle the diagnosis in order to portray the case in the most severe light.
Build-ups are most common in workers' compensation and personal-injury cases. It is not uncommon to see 10 or more diagnoses in build-ups of these cases.
While much of the gaming by doctors is done out of loyalty to the patient or out of pure frustration, it is still inappropriate, and the end result is not worth the risk to the doctor and practice. Doctors should avoid gaming procedures in diagnosis coding and all other aspects of third-party pay. The table above provides examples of the coding procedures to be avoided in order to prevent accusations of gaming.
The soon-to-be-released ICD-10 contains substantially more codes than the ICD-9. Providers should make sure they are current on any and all code changes when the new version is released for use. (An exact release date has not been announced as of press time, but the original October 2013 date has been delayed by Health and Human Services, as reported in the April 22 issue of DC. For more information, read "ICD-10, 5010 Compliance Delayed" online or in the print issue.)
Click here for more information about K. Jeffrey Miller, DC, MBA.
Dr. N. Ray Tuck Jr. is the chairman of the American Chiropractic Association Board of Governors.