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MODIFIER 59 AND SUBSET MODIFIER XE, XS, XP and XU

Posted on by kellyausiello

MODIFIER 59 AND SUBSET MODIFIER XE, XS, XP and XU

Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code. CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS) and provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:

  • To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery
  • To indicate that a procedure was performed bilaterally or to designate laterality (LT/RT)
  • To report multiple procedures performed at the same session by the same provider. • To report only the professional component or only the technical component of a procedure.
  • To designate performance on a specific part of the body (ie T3=L foot 4th digit.)

More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes.

Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational but all are typically necessary to avoid denials.

Modifiers are not intended to be used to report services that are “similar” or “closely related” to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service.

Modifier Definitions: Modifier 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same day, see modifier 25.

Effective for dates of service January 1, 2015 and following, CMS established four new HCPCS modifiers to define subsets of the -59 modifier, to better define the “Distinct Procedural Service.” These modifiers are XE, XS, XP, and XU. (collectively referred to as -X{EPSU}. Where:

  • XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
  • XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ or Structure
  •  XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
  •  XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier and since The -X{EPSU} modifiers are more selective versions of the -59 modifier, it would be incorrect to include both the 59 modifier and a subset modifier on the same line.

Different Organs/Contiguous Structures:: From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example: Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.”

Incorrect use of modifiers XE, XP, XS, XU, or 59:

  • Procedures in the same anatomical site (e.g. digit, breast, etc.), even with incision lengthening or contiguous incision.
  • CPT identified “separate” procedures performed in the same session, same anatomic site, or orifice. • Laparoscopic procedure converted to open procedure.
  • Incisional repairs are part of the global surgical package, including deliveries and cosmetic improvement of a previous scar at the location of the current incision.
  • Contiguous structures in the same anatomic site or organ system. (See Coding Guidelines “Different Organs/Contiguous Structures” and CCI Policy Manual, chapter 1.

**** Modifier XP should not be used to identify two providers of the same specialty in the same clinic to bypass global surgery package rules, new-patient visit edits, or other same-specialty rules.

Breathe A Little Easier Billing Nebulizer Treatments.

Posted on by kellyausiello

Coding for multiple nebulizer treatments is one of our “dual rule” issues where Medicare and other carriers who follow Medicare guidelines, differ from the AMA’s CPT™ instructions.

As of CPT 2016, CPT code 94640 describes treatment of acute airway obstruction with inhaled medication and/or the use of an inhalation treatment to induce sputum for diagnostic purposes. The language change was to clarify the intent that this be a “bundled code” representing both the diagnostic and therapeutic services. It does NOT however bundle multiple units.

According to the CPT™, when a patient receives multiple aerosol treatments on the same date, you should use 94640 for the first treatment and repeating subsequent treatments with the same code as a separate line item and adding require modifier 76 (Repeat procedure by same physician).

Therefore, you would code the example of two consecutive nebulizer treatments as:

  • 94640–first treatment
  • 94640-76 x 1 subsequent treatment.

For the inhalation solution, you should report two units of J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg). Because J7613 represents one -unit dose.

A standard treatment session takes about 10 minutes and the patient should see some relief within 15 minutes. We understand from our physicians that one additional application is fairly common in the clinical setting especially in Urgent Care settings.

If a patient receives “back-to-back” nebulizer treatments exceeding 1 hour, (which rarely occurs in urgent care), you would bill CPT code 94644, “Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour,” and, if applicable, CPT code 94645, “Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour”, instead of CPT code 94640.

While CMS agrees with the rationale that code 94640 represents both the diagnostic and therapeutic services, they also ignore the AMA guidance and bundle multiple units.

Medicare: NCCI Policy Manual -2018; Chapter 11, J8. Page 26. CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction…) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes.

CPT code 94640 shall only be reported once during an episode of care regardless of the number of separate inhalation treatments that are administered. (Under Medicare regulations, an episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.)

If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) shall not be reported separately. The inhaled medication may be reported separately however, depending on the payer’s rules, the medication may also be bundled to the service.

The medications administered in the urgent care setting are most commonly a form of albuterol. You will find the correct codes to use in the “Healthcare Common Procedure Coding System Level II” (HCPCS) coding manual. Below is a list of Federal Drug Administration (FDA)-approved medication containing albuterol:

  • J7611, “Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg”
  • J7612, “Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DEM, concentrated form, 0.5 mg”
  • J7613, “Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg”
  • J7614, “Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg”
  • J7620, “Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME”

There are several respiratory or pulmonary conditions that typically qualify for inhalation treatment coding, such as:

  • Asthma, (J45.-)
  • Acute bronchitis, (J20-)
  • Chronic obstructive pulmonary disease (COPD), (J44-)
  • Pneumonia, (J18.-)
  • Acute bronchospasm, (J98.01)
  • Cough, (R.05)
  • Wheezing, (R06.2)
  • Shortness of breath, (R06.02)

In summary, mark this code as having one unit billing for Medicare but multiple sessions to most major medical carriers. Remember to “justify” an additional session in your notes by showing incomplete relief from the first dose after a reasonable expected response time (ie 15-20 min).

CPT Modifiers 96 & 97 for Habilitative and Rehabilitative Services

Posted on by kellyausiello

Effective January 1, 2018, CPT modifiers 96 “habilitative services” and 97 “rehabilitative services” will be in effect for use.  CMS deleted modifier SZ as of December 31, 2017 and added modifiers 96 and 97 to their edits.

  • (MLN Matters MM10385). 1/1/2018 — Add the following new modifiers to the valid modifier list;
    – FY: Computed radiography x-ray
    – JG: 340B Acquired Drug
    – TB: Tracking 340b acquired drug
    – X1: Continuous/broad services
    – X2: Continuous/focused services
    – X3: Episodic/broad services
    – X4: Episodic/focused services
    – X5: Svc req by another clinician
    – 96: Habilitative services
    – 97: Rehabilitative services

Private payers will probably adjust their policies to use the 96 and 97 modifiers as well, but you should confirm that with a benefits representative. The addition of a valid CPT modifier should NOT cause a reject and the new modifiers DO clarify your claim for the carrier.

The two new modifiers were created to identify services as habilitative or rehabilitative and made their appearance in the 2018 CPT™;

Modifier 96 Habilitative Services: When a service or procedure that may either be habilitative in nature or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96- to the service or procedure code to indicate that the service or procedure provided was habilitative. Such services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.

Modifier 97 Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97- to the service or procedure code to indicate that the service or procedure provided was rehabilitative. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.

Simply put, rehabilitative services help patients restore functions or skills that have been lost, while habilitative services develop skills and functions that had not been developed previously.

Now that CMS has deleted modifier SZ in favor of the AMA’s 96 and 97, and naturally expect these modifiers to be reported with services such as physical medicine and rehabilitation codes allowing the payer the ability to differentiate habilitative from rehabilitative services.

This differentiation is required by the Patient Protection and Affordable Care Act.

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices. Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient. The services are not only beneficial for the patient but are a good source of revenue for the practice. Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately, many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the physician’s office setting.

As a result, practitioners are learning the rules the hard way as a whistle blower, disgruntled employees or competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist. Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.
Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

• an assessment by a physician, NPP or therapist supports utilization of the intervention,
• there is documentation of objective physical and functional limitations (signs and symptoms), and
• the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist; for Medicare reimbursement means that the covered therapy services were “personally performed by one of the following individuals;

• Licensed therapy professionals: licensed physical therapists and occupational therapists
• Licensed PTA with appropriate supervision by a licensed physical therapist.
• Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
• Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
• Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
• Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
• “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.
o Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed. (Otherwise called an “unlicensed graduate PT/OT”).

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations. Knowledgeable consultants know  that reimbursement for skilled services have an included calculated component based on the amount of “professional” time required to render the service to the patient. You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure.

The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are NOT therapy services in the outpatient setting and are NOT covered by Medicare.

  • Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services.
• This includes service performed by Chiropractors since Medicare will not pay for any service performed, ordered or supervised by a Chiropractor.

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”. Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

  • Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law.
  • Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of licensure. Qualified personnel have been educated and trained as therapists and qualify to furnish therapy services under direct supervision and incident to a physician or NPP.

So next time, your so-called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.

Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The primary difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?
In either case, the key component is that the perpetrator knew or should have known that the act was improper and under the revised false claims act you could face the possibility of treble damages and civil penalties of up to $11,000 for each improper claim and full membership in the exclusive OIG’s excluded individuals club !

Therapy Claims for 2018 and beyond for Medicare.

Posted on by kellyausiello

After decades of monitoring the annual Medicare therapy caps and temporary exceptions fiascos, I got an early morning call from a Washington DC friend contact that Congress had finally “repealed” the cap on therapy services.

It was well into the early morning hours when the Senate finally voted 71-28 to pass a budget bill known as the Bipartisan Budget Act of 2018 .

I knew word would spread fast and my phone would soon start ringing so I quickly reviewed the bill’s language and found we still had a cap at $2010 but it had been changed back to a “soft” cap and the exception process missing from the previous legislation in January, had now been provided.

Section 50202 – Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy – The new law requires for services after December 31, 2017:
* Medicare claims are no longer subject to the therapy caps (one for occupational therapy services and another for physical therapy and speech-language pathology combined);
* Claims for therapy services above $2010, the same amount as the previous therapy caps, must include the KX modifier indicating that such services are medically necessary as justified by appropriate medical record documentation; and
* Claims for therapy services above $3,000 of incurred expenses may be subject to targeted medical review.

So, the threat of a hard cap is gone and Medicare beneficiaries can still obtain necessary therapy services beyond the $2,010 limit as long as you affix the KX modifier to the claim.

Discipline Modifiers:
CMS also implemented a requirement for billing therapy services by ANY PROVIDER. (MM101076) effective 1/1/2018 set an additional billing requirement for any “always therapy” service provided by any provider specialty type. The instruction informed all providers that each code designated as “always therapy” must always be submitted with one of the therapy discipline modifiers GN, GO or GP in addition to any other relevant payment modifier like the KX modifier.

Based on this policy change, even a chiropractor providing an always therapy service must append the appropriate therapy modifier (normally GP) for the service being billed IN ADDITION TO modifier GY to indicate the service is non-covered by Medicare for their provider type.

Many Chiropractic offices are having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance just because they did not append the default GP discipline modifier to the therapy line items.

A rejected claim does NOT PROCESS through the system at all and therefore does not generate a valid denial for purposes of collection from the patient or their secondary coverage carrier. Offices that are not following the new reporting requirements have found themselves in a revolving door of re-submissions.

If, on any claim from any provider, one of the therapy modifiers, GN, GO or GP, is not appended then the claim will reject and not process through the Medicare processing system for denial.

You will need to refile the claim with the appropriate modifiers for it to process for denial.

The last battle: To offset future costs associated with eliminating the hard cap, Congress also enacted a payment differential for PTAs and COTAs like that used for Physician Assistants and Nurse Practitioners, which means therapist assistants will be reimbursed 85% of the amount PTs and OTs receive for the same services.

This reduction is set to go into effect on January 1, 2022 and will have more impact on “facilities and rehab agencies” than the Part “B” office setting where direct supervision of an enrolled PT or OT is required.

Baring any legislative actions to the contrary, we should be firmly set on the issues of caps and exceptions until the end of 2027.

Can I Treat My Partner’s Mother and Bill Medicare?

Posted on by kellyausiello

Can I Treat My Partner’s Mother and Bill Medicare?

By R.L. “Ron” Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.

The regulations on treating immediate relatives are found in the Medicare Benefits Policy Manual, Pub 100-02 in Chapter 16 (General Exclusions From Coverage) Section 130.  To better understand these regulations, you must first be familiar with the definitions of “provider and supplier” as used in all Medicare regulations.

Provider is defined at 42 CFR §400.202 and generally means a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency or hospice, that has in effect an agreement to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization services.

Supplier is also defined in 42 CFR §400.202 and means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.

In general, Medicare excludes payment for services rendered by a physician or other practitioner not only to their own immediate relatives but also to relatives of the owner or owner’s of the practice entity. (130-A.)

“The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.”.

 Immediate Relative, as defined in regulations includes;

  • Husband and wife;
  • Natural or adoptive parent, child, and sibling;
  • Stepparent, stepchild, stepbrother, and stepsister;
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
  • Grandparent and grandchild; and
  • Spouse of grandparent and grandchild.

There are some minor exceptions but basically these prohibitions also survive divorce or death of the actual relative.  In a stated example within the regulations, (130 B.) we see;

“For example, if a provider treats the stepfather of the owner after the death of the owner’s natural mother or after the owner’s stepfather and natural mother are divorced, or if the provider treats the owner’s father-in-law or mother-in-law after the death of their spouse, the services are considered to have been furnished to an immediate relative, and therefore, are excluded from coverage.”

Current regulations also extend to “members of the patient’s household” who share a single family unit dwelling and includes their (live in) domestic employees.

 “These are persons sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.”

The prohibition of payment for services rendered to the immediate relatives is quite broad and applies whether the provider or supplier is a sole proprietor or a partnership in which even “one of the partners” is related to the Medicare patient and extends to any “incident to” services that may be provided by a nurse or technician.(130 E)

What if my PA or NP treats the relative?

Under Medicare regulations, 130 F, “This exclusion applies to charges imposed by a non-physician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who has an excluded relationship to the patient, or by a partnership in which even one of the partners is related.”

Under regulation 130 D, Regulations state;  “Professional corporation means a corporation that is completely owed by one or more physicians, and is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by State law. Any physician or group of physicians which is incorporated constitutes a professional corporation.”

 The regulations provide an “exception” for the stockholders, officers or directors of a corporation (other than a professional corporation) however you should definitely check with a competent healthcare law attorney for a legal opinion on how your “particular corporation” would actually be viewed under the Medicare rules.

Summary: The Medicare regulations would appear to prohibit your billing for services rendered to your partner’s mother or any other immediate relative of any partner within your practice.  I would suggest you refer the patient to a physician that is not associated with your practice or provide the care at no cost to anyone.

 The discussion presented above is offered only as an overview of Medicare regulations and is not intended to be, or construed by the reader as being a legal opinion or legal advice.  Private carrier policies may vary in coverage on this subject.  While the author has made a good faith attempt to present the discussion accurately, the discussions presented are base on lay-interpretation of the issues and should not be viewed as an attempt to offer or render legal advice or opinion or otherwise engage in the practice of law.  The discussion presented is, at best, of a general nature and cannot be substituted for the advice of a licensed attorney at law with specialized knowledge in healthcare regulatory issues.
 The M.A.A.M.A. and the Medcorp Compliance Network always advise physicians and other practitioners to seek the advice and legal opinion of a licensed healthcare law attorney in your home State as your only authoritative interpretation of all matters of law and regulation for Federal, State and individual carrier coverage issues.

Moderate Sedation – 2017

Posted on by kellyausiello
References: CR10001 – Medicare Claims Processing Manual – Pub 100-04 Chapter 12, Sections 50 and 140.   https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Effective May 15, 2017 CMS revises their manual to bring it in line with current payment policy for moderate sedation and other anesthesia services in light of the CPT changes for January 1, 2017.

Anesthesia services range in complexity from least to the most complex as follows:

  • local or topical anesthesia,
  • moderate (conscious) sedation,
  • regional anesthesia and
  • general anesthesia.

General Payment Rule:

The fee schedule amount for physician anesthesia services furnished is typically based on the allowable base and time units multiplied by an anesthesia conversion factor specific to the geographic locality and communicated to the MACs by means of the annual updates to the Healthcare Common Procedure Coding System (HCPCS) file. The base units and conversion factor are available at https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html

Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation but does not include minimal sedation, deep sedation or monitored anesthesia care.  Practitioners are instructed to report the appropriate CPT and/or HCPCS code that accurately describes the moderate sedation services performed during a patient encounter, which are performed in conjunction with and in support of a procedural service, consistent with CPT™[1] guidance.

CPT codes 99143-99150 previously used for reporting moderate sedation were deleted from CPT 2017™ and replaced with;

NEW

99151

  

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
99152     initial 15 minutes of intraservice time, patient age 5 years or older
 

 

99153

  

each additional 15 minutes intraservice time (List separately in addition to    code for primary service)   [Regardless of age of patient.]
99155 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
99156     initial 15 minutes of intraservice time, patient age 5 years or older
99157     each additional 15 minutes intraservice time (List separately in addition to code for primary service)

 

According to the AMA guidelines,

Preservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

Intraservice time:

  • is used to determine the appropriate CPT code to report moderate sedation services:
  • Begins at the administration of the sedating agent(s);
  • Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified healthcare professional providing the sedation and personal continuous face-to-face time with the patient;
  • Includes ordering and/or administering the initial and subsequent doses of sedating agents;
  • Requires continuous face-to-face attendance of the physician or other qualified healthcare professional;
  • Requires monitoring patient response to the sedating agents, including:
    • Periodic assessment of the patient;
    • Further administration of agent(s) as needed to maintain sedation; and
    • Monitoring of oxygen saturation, heart rate, and blood pressure

Intraservice time of less than 10 minutes should NOT be reported.

If the physician or other qualified healthcare professional who provides the sedation services also performs the procedure supported by sedation (99151, 99152, 99153), the physician or other qualified healthcare professional will supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

An independent trained observer is defined as an individual who is qualified to monitor the patient during the procedure and who has no other duties during the procedure.

Postservice Work

The postservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the A/B MAC (B). There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.

[1] CPT is a registered trademark of the American Medical Association, used with permission.

Fraud Enforcement UP UP UP! Are you next?

Posted on by kellyausiello

20 Years after HIPPA established a national Fraud and Abuse Control Program, the enforcement agencies are still providing impressive results.

During Fiscal Year (FY) 2016, the Federal Government won or negotiated over $2.5 billion in health care fraud judgments and settlements. As a result of these efforts, as well as those of preceding years, they recovered over $3.3 billion.

The Department of Justice (DOJ) opened 975 new criminal health care fraud investigations, filed criminal charges in 480 cases involving 802 defendants and secured a total of 658 convictions Also in FY 2016, DOJ opened 930 new civil health care fraud investigations and had 1,422 civil health care fraud matters pending at the end of the fiscal year.

FBI investigative efforts resulted in over 555 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 128 health care criminal enterprises.

In FY 2016, investigations conducted by HHS’ Office of Inspector General (HHS-OIG) resulted in 765 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 690 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters.

HHS-OIG also excluded 3,635 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.

New Exclusion Authority and Penalties:
On Dec. 6, 2016, the OIG issued rules that incorporate new civil monetary policies (CMP) authorities, clarify existing authorities, and reorganize regulations regarding CMPs. The final rule also implements provisions of the PPACA of 2010 that authorize CMPs for the following;
*Failure to grant the OIG timely access to records.
*Ordering or prescribing while excluded.
*Making false statements, omissions, or misrepresentations in an             enrollment application.
*Failure to report and return over-payments.
*Making or using a false record or statement material to a false or   fraudulent claim.

In addition, under both the Federal Civil Penalties Inflation Act and the 21st Century Cures Act, Congress adjusted certain civil fines and penalties for inflation and increased the OIG’s authority to issue exclusions for the following:
• Expand CMP for false claims related to contracts and grants funded by Medicare and Medicaid or other HHS programs.
• Authorize the OIG to impose CMP on individuals or entities that knowingly submit false claims, up to $10,000 for each claim.
• Expansion would include false statements on applications or proposals for HHS-funded grants/contracts, up to $50,000 for each false statement.
• $15,000 for each day the entity fails to allow OIG access to audit or investigate false claims.
• Filled in a gap to expand OIG authority to allow the imposition of exclusion of an officer or managing employee who left the organization prior to the pursuit of fraud that such person was involved in, even if they are not currently employed by the prior company.

Fraud and/or abuse differ only in the “intent” of the person committing the offense.  Most “abuse” cases are pursued as civil actions while actual “fraud” with intent are criminal.  In other words, fraud can send you to the “big house” while stupidity just sends you to the “poor house”.

Medicare Audits Result In Large Paybacks on Therapy Services.

Posted on by kellyausiello

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By R.L. Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.  Executive Director. 

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices.  Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient.  The services are not only beneficial for the patient but are a good source of revenue for the practice.  Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the non-facility (Doctor’s office) setting.

Practitioners are learning the rules the hard way as whistle blower, disgruntled employees and competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist.  Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.

Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

  • an assessment by a physician, NPP or therapist supports utilization of the intervention,
    there is documentation of objective physical and functional limitations (signs and symptoms), and
  • the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist, for Medicare reimbursement privileges means that the covered therapy services are “personally performed ONLY by one of the following;

  • Licensed therapy professionals: licensed physical therapists and occupational therapists
  • Licensed PTA with appropriate supervision by a licensed physical therapist.
  • Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
  • Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
  • Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
  • Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
  • “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed.

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations.

The basic facts are that reimbursement for services performed have a calculated component based on the amount of “professional” time required to render the service to the patient.  You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure.  The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services.      (This includes services performed by Chiropractors since they are statutorily excluded  for payment for any service performed other than spinal manipulation by CMT.- DrR)

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”.  Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

  • Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law……..o    Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of a license. Qualified personnel must have been educated and trained as therapists to qualify for furnishing therapy services under direct supervision and incident to a physician or NPP.

PTAs, even if licensed, may NOT perform “incident to” a physician or NPP, since they do not meet the definition of a therapist.

Aides are “everyone other” than those described above.  Med Techs, Chiropractic Assistants, Exercise Physiologists, Athletic trainers, massage therapists, LVNs, LPNs or any individual with a certificate of anything are NOT eligible to perform PT/OT for Medicare reimbursement.

So next time, your so called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.
Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The only difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?

In either case, the key component is that the perpetrator knew or should have known that the act was improper.  

There are many “restrictions” providing PT / OT –  Don’t hesitate to contact us with questions.

Merit-based Payment System (MIPS)

Posted on by kellyausiello

MAAMA SmallMerit-based Payment System (MIPS) 

Writing for the Academy is Dr R.L. Ramsdell, PhD – Executive Director. 

The Centers for Medicare & Medicaid Services (CMS) has added another 900+ page volume to our regulation reading pleasure outlining the proposed details on how physicians will be paid under Medicare in 2019. As I stated, this is a proposal open for public comments, submitted electronically or on paper, until 5 p.m. on June 27, 2016.

There are actually two programs here, the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) incentive regulation. According to CMS, the MIPS will consolidate components of three existing programs: the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs). The proposed rule also would establish incentives for participation in certain alternative payment models (APMs) to help advance the Obama Administration’s 2015 goals to move 30% of traditional Medicare fee-for-service payments into alternative payment models that pay providers based on the quality rather than the quantity of care they provide by 2016 and 50% by 2018.

The current proposal is a result of the 2015 law called the Medicare Access and CHIP Reauthorization Act (MACRA), which, after decades of “temporary fixes”, finally abolished the idiotic and unsustainable -sustainable growth rate (SGR) formula for physician compensation. MACRA, as it is now known, gradually shifts reimbursement from fee-for-service to pay-for-performance or value based payment.

Under MACRA, physicians choose between two payment models with MIPS being the default model which will encompass the majority of physicians. MIPS reportedly will incorporate and align three existing Medicare incentive programs:

• meaningful use of electronic health records,
• the Physician Quality Reporting System, and
• the Value-Based Payment Modifier.

Medicare will increase or decrease a physician’s fee-for-service reimbursement in MIPS according to his or her quality of care, cost (resource use), clinical practice improvement, and meaningful use of electronic health records (advancing care information).

Our understanding in reading the proposed regulation is MIPS will be based on a “point score” system for the first year where the quality-of-care component constitutes 50% of the MIPS score; cost 10%; clinical practice improvement 15%; and advancing care information (meaningful use of electronic health records) 25%.

MIPS bonuses and penalties up to 4% each debut in 2019 and increase to

  • 5% in 2020,
  • 7% in 2021, and
  • 9% in 2022 and beyond.

The bonuses and penalties are based on performance 2 years earlier, meaning pay hikes and pay cuts in 2019 will reflect what a clinician did in 2017.

Let’s look briefly at the “scoring” components.

• Quality (50 percent of total score in year 1): For this category, clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices.

• Advancing Care Information (25 percent of total score in year 1): Medicare incorporated EHR and meaningful use into this new catchy term late last year) For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.

• Clinical Practice Improvement Activities (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices’ goals from a list of more than 90 options.

• Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims, meaning no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.

Advanced Alternative Payment Models

Under provisions originally created by the Affordable Care Act, many clinicians are currently participating in alternative payment models but may not meet requirements for sufficient participation in the most advanced models under the new regulations. The proposed rule appears to be designed to provide these clinicians with financial rewards within MIPS. Further it appears that those clinicians who can participate to a sufficient extent in Advanced Alternative Payment Models – would be exempt from MIPS reporting requirements and qualify for financial bonuses under the new models.

These models include the new Comprehensive Primary Care Plus (CPC+) model, the Next Generation ACO model, and other Alternative Payment Models under which clinicians accept both risk and reward for providing coordinated, high-quality care.

Let’s look at these as they are presented by CMS in the proposal.

The Comprehensive Primary Care Plus (CPC+) model
On April 11, CMS announced its largest-ever initiative to transform how primary care is delivered and paid for in America. The initiative, called The Comprehensive Primary Care Plus (CPC+) model, is a national advanced primary care medical home model which will be implemented in up to 20 regions to accommodate up to 5,000 practices.
According to CMS, the initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to be paid for achieving results and improving care.

• The CPC+ model incorporates lessons learned from the 5 year CPC initiative model tested through the Center for Medicare & Medicaid Innovation that began October 2012 and runs through December 31, 2016. Under this initiative model, CMS collaborated with 38 commercial and state health insurance plans across seven U.S. regions to support 500 primary care practices in testing aligned payment for the delivery of a single model of comprehensive primary care.

o In addition to regular fee-for-service payments, Medicare and other CPC payers provide a non-visit-based care management fee paid per member per month and an opportunity to share in savings generated in each of the CPC regions. This care management fee has provided CPC practices with the necessary financial resources to create new workflows, hire care management staff, and develop new relationships necessary to coordinate care.

• Center for Medicare and Medicaid Innovation (Innovation Center), was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). Congress created the Innovation Center to test innovative payment and service delivery models, including primary care payment and care delivery reform, to reduce CMS program expenditures and improve quality for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.

Primary care practices will participate in one of two tracks. While both tracks will be required to meet the criteria of the model, those in Track 2, will actually provide more comprehensive services for patients with complex medical and behavioral health needs.

CPC+ is reportedly designed to help practices move away from one-size-fits-all, Fee-For-Service (FFS) health care to a new system that will give doctors the freedom to deliver the care that best meets the needs of their patients.

• In Track 1, CMS will pay practices a monthly care management fee in addition to the FFS payments under the Medicare Physician Fee Schedule for activities

• In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare FFS payments for Evaluation and Management services, will receive a hybrid of reduced Medicare FFS payments and up-front comprehensive primary care payments for those services

o CMS has a fact sheet on fees and payments available at:  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-11.html

CMS states “to promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. Practices in both tracks also will receive data on cost and utilization.”

CPC+ will bring together CMS, commercial insurance plans, and State Medicaid agencies to provide the financial support necessary for practices to make fundamental changes in their care delivery and select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will enter into a Memorandum of Understanding with selected payer partners to document a shared commitment to align on payment, data sharing, and quality metrics in CPC+. CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.

For additional information on the “specifics” of the CPC+ program, we refer the reader to;
https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus

The Next Generation ACO Model is a new CMS Innovation Center initiative that builds upon experience from the Pioneer ACO Model and the Shared Savings Program. With 21 participating ACOs, the new model offers a new opportunity in accountable care—one that enables providers and beneficiaries greater opportunities to coordinate care and aims to attain the highest quality standards of care. Unlike other models, this model includes a prospectively (rather than retrospectively) set benchmark, allows beneficiaries to choose to be aligned to the ACO, and tests beneficiary incentives for seeking care at Next Generation providers, including increased availability of telehealth and care coordination services.

The Next Generation Model participants will have the opportunity to take on higher levels of financial risk – up to 100 percent risk – than ACOs in current initiatives. While they are at greater financial risk they also have a greater opportunity to share in more of the Model’s savings through better care coordination and care management. In addition, the ACOs will receive their budgets prospectively, in advance of the performance year, to plan and manage care around these financial targets from the outset. The ACOs will also be able to select from flexible payment options, such as infrastructure payments that support ACO investments in care.

There are 18 ACOs currently participating in the Next Generation ACO Model in 14 States.

For more information on the Next Generation ACO Model, including the list of provider participants, and how to apply for 2017, we refer the reader to:
https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/

Deadline for submission of your letter of intent (LOI) has been extended to May 20, 2016. The actual application must be received by May 25th.

The Next Generation ACO Model is an initiative designed for ACOs that are very experienced in coordinating care for large populations of patients.

The Academy does NOT recommend this for our member practices.

Under the current proposal, as we understand it, we would suggest our members choose the MIPS program and strive to fully participate in that to receive their financial incentive bonuses.

The real risk of carrier audits!

Posted on by kellyausiello

Let’s face it, many practices are having a hard time staying profitable and may engage in some “creative billings” to increase what they are paid by various carriers. For some reason, practices seem to think that Medicare/ Medicaid/ and Tricare are their only real concerns when it comes to misrepresenting services for financial gain.

SadTypically their first concern arises when they receive a letter from an investigations unit requesting several patient files for specific dates of service that the carrier bases on their provider participation agreement authorizing the plan(s) to perform reviews, audits and statistically valid sampling techniques for peer review program activities, medical necessity reviews, data validation reviews, billing and claims payment audits, coding or quality review audits; all of which routinely hold all physicians in the practice jointly and severally liable for misreporting by any and all providers in the practice.

Healthcare fraud is a crime under most criminal codes and consists of intentional deceit within the healthcare system for the purpose of illicit gains. Healthcare abuse is similar activity or behavior where knowing intent to obtain an unlawful gain cannot be established.
The primary difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime? In either case, the key component is that the perpetrator knew or should have known that the act was improper or inconsistent with sound practices.

It’s important to distinguish health care fraud from mere mistakes, omissions, or improper payments. To commit fraud, a person must knowingly engage in a plan, scheme, or activity to provide falsehoods or misrepresentations with the intent to achieve some financial gain.

The proof of the allegations is the existence of the claims regardless of the payment or denial. The scheme does not need to be successful to be considered fraudulent.

Most practices referred by the carrier for criminal actions are due to intentional misrepresentation of the procedure performed and willful misconduct by the providers, managers and billing people to mis-code the actual service(s) and falsify the medical records to support the misrepresented service codes. The “collaboration” of the parties to the scheme is usually prima facie evidence of intent and the testimony of one of the more innocent collaborators who rolls over on the boss, is all it takes to prove intentional fraud.

Stealth Coding.
The “basic instructions” on code selection contained in the CPT®* manual prohibits “stealth” coding.
“Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. ………When necessary, any modifying or extenuating circumstances are added. Any service or procedure should be adequately documented in the medical record.”

Conservative estimates of the amount of healthcare expenditures lost to fraud is three percent of total services paid, which equates to over $70 billion annually. Frequently seen examples are;

• Billing for more expensive services or procedures than were actually provided or performed, commonly known as “upcoding”-i.e., falsely billing for a higher-priced treatment than was actually provided. This is often combined with an accompanying “inflation” of the patient’s diagnosis code to a more serious condition consistent with the false procedure code.
• Performing medically unnecessary services solely for the purpose of generating insurance payments-seen very often in nerve-conduction and other diagnostic-testing schemes.
• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments- This is often seen in multidisciplinary settings where a non-covered service such as spinal manipulation or extremity adjustments by a Chiropractor are represented as a covered physical therapy procedures under order of a medical provider.
• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.
The majority of health care fraud is committed by a very small minority of dishonest health care providers.

Sadly, the actions of these deceitful few ultimately serve to sully the reputation of perhaps the most trusted and respected members of our society-our physicians. Unfortunately these fraud-doers take advantage of the confidence that has been entrusted to them in order to commit ongoing fraud on a very broad scale and their ability to spread false billings among many insurers simultaneously including public programs such as Medicare and Medicaid, where they can maximize fraud proceeds while lessening their chances of being detected by any a single insurer.

Federal Criminal False Claims Statutes (18 U.S.C. §§ 287,1001) Section 1001 applies to anyone whose action(s) related to any claim(s) for government payment consist(s) of any of the following:
• Falsifying, concealing, or covering up by any trick, scheme or device a material fact related to any claim(s) for government payment;
• Making any materially false, fictitious or fraudulent statement or representation; • Making or using any false writing or document knowing it contains any materially false, fictitious or fraudulent statement or entry.
Section 287 states that whoever makes or presents to the government a claim knowing that it is false, fictitious or fraudulent shall be imprisoned and subject to fines.
We understand from attorneys that the government is required to establish all of the following in regard to the action(s) of a false claim(s) case defendant. He/she:
• Made or presented a false, fictitious or fraudulent claim to a department of the United States;
• Knew the claim was false, fictitious or fraudulent; and
• Did so with the specific intent to violate the law or with awareness that what s/he was doing was wrong.

EMPLOYEES BEWARE: Bosses are not doing their employees any favors when the intimidate them to “do as they are told”. Filing false and miscoded claims can seem like a minor crime, but a conviction for health care fraud, especially when the defendant is a professional who depends on a license to practice, can irreparably change the course of that professional’s life. “My boss made me do it” is normally NOT going to get you absolve you of your participation in perpetrating the crime or conspiracy to cover it up.

As carriers improve investigative techniques through their National Health Care Anti-Fraud Association and refer more cases for criminal action in addition to recovering their money, we need to offer the following advice to our members;
The moment you are approached by investigators about a potential fraud case, you need to contact a criminal defense attorney. You can unknowingly incriminate yourself anytime you speak to an investigator if you don’t have legal advice. Local criminal defense attorneys are the only people capable of providing you with legal advice in light of their knowledge of the law, as well as their experience with local prosecutors, courts, and criminal investigations.

If you’re being investigated for breaking a federal law, your case will be handled in the federal court system. Be sure that the lawyer you choose has experience handling federal cases.

Naturally the best defense is to do it right in the first place.
If you are unsure of a particular billing scenario or you get a “I get paid doing this” from a “friend”, Contact us! Your Academy is here to help you.

*CPT is a registered trademark of the American Medical Association- gratefully used with their permission.