Wiki Preventive physical exams, Medicare patient

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cmercado0526

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Hi everyone! Before I continue I want to clarify that this has absolutely nothing to do with the Medicare AWV. This is a hands on, head to toe, physical exam. A patient comes in every year and has the same thing, clearly documented, coded 99396 through age 64. Now this patient is on Medicare, has the same thing, clearly documented, but the provider knows Medicare doesn't cover it so she calls it an 'annual review' and leaves the Z00.00 out of the Impressions & Recommendations. She'll use their diagnostic issues, if they have any. She will do the exact same exam on two different patients and call them two different things. (Apparently she doesn't seem to care, or know, that medical necessity may only get her a 99212). Am I the only one who sees a problem with this?
Thanks for your opinions!
Cathy
 
I am not a lawyer but knowingly and purposely misreporting diagnosis to make a non-covered service payable sounds like fraud to me. Under the Federal False Claims Act (since this is Medicare) I don't think one can even plead ignorance. Hopefully someone more experienced with E&M will chime in especially since people perform well and sick visits on the same date of service there might be exceptions but how to document it properly is over my knowledge level.
 
Thank you! She thinks she works for the patient and they should not have to pay. I tried to explain to her that I 'carve out' whatever diagnostic part of the visit I can to make the patient responsibility as little as possible. I mentioned that 5 letter word to her - fraud - and she freaked out saying I was accusing her. Well, if it walks like a duck and talks like a duck....... I just wanted more opinions for when I go to my boss and tell him I will not send these charges to Medicare.
 
Knowingly, and willfully misrepresenting services in order to have financial gain falls under the False Claims Act, and can be a potential for a serious audit from CMS, including but not limited to fines, exclusions, and more...

The provider needs further education.
 
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