Part B Insider (Multispecialty) Coding Alert

Published on Tue Oct 21, 2003 PDF

Patients slip through the cracks, agency states

Few beneficiaries are receiving all the preventive benefits that Medicare is supposed to cover, the General Accounting Office states in a new report titled "Most Beneficiaries Receive Some but Not All Recommended Preventive Services" (GAO-03-958).

The report, submitted to the chairman of the House Commerce and Energy Subcommittee on Oversight and Investigations, found that about 30 percent of beneficiaries didn't receive flu shots in 2000 and 37 percent had never been vaccinated against pneumonia. A 1999-2000 survey of patients with high cholesterol found that a third had never been told this fact by their physicians.

The 2004 update to the Healthcare Common Procedure Coding System will reach Medicare contractors Oct. 15, the Centers for Medicare & Medicaid Services says in a program memorandum (AB-03-140; http://cms.hhs.gov/manuals/pm_trans/AB03140.pdf). CMS states that the American Medical Association has established some new category II codes (ending with the letter "F") that will be used to track performance measurement.

CMS proposes to add a new measure to its Participating Physicians Directory, one that tracks whether physicians accept all new Medicare patients. The directory now includes names, contact info and specialties of Medicare participating physicians who have agreed to accept assignment on all Medicare claims and covered services.

Great Falls, Va., neurologist Dr. Abdorasool Janati and his wife and office manager, Forouzandeh Janati, were indicted Sept. 11 on one count of conspiracy and 61 counts of healthcare fraud for allegedly upcoding and billing for services not rendered. The Janatis now face up to 315 years in prison if convicted on all counts.

Abdorasool Janati was the primary physician at the Neurological Institute of Northern Virginia. The indictment alleges that the Janatis "authorized office staff to bill under the office visit code which generated the highest payment, i.e., CPT Codes 99215, without regard for the requirements for the use of the CPT code as set forth in the CPT reference manual."

CPT code 99215 requires at least two of these components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Such visits usually involve presenting problems of moderate to high severity and 40 minutes of face-to-face time with the patient or family members.

In addition to the E/M upcoding, the Janatis are also charged with billing for nerve-conduction tests, needle elec-tromyography tests, and brain-wave studies that were never performed.