Urology Coding Alert

There's only one exception to the rule, and we'll show you what it is One of your urologists wants you to report a procedure under the name of another physician who also works in the same practice but under a different tax ID number -- but should you do it? Provider misidentification does happen -- sometimes intentionally and sometimes accidentally -- but either way, it shouldn't happen and could result in a serious problem for your practice and for all of your physicians. Let our experts guide you to ensure you report physician services compliantly and avoid fraudulent claims.
Turn to CMS Form for Guidance The basics: The name and identification number (NPI/PIN) you enter on the CMS-1500 form must be the name and number of the provider who actually rendered the service to the patient. The only exception to this rule is incident-to billing. Warning: Don't report one physician incident-to another physician, because incident-to applies only to nonphysician practitioners. Clearly stated: On the back of the CMS-1500 form, there is a statement indicating that physicians are specifically certifying that they performed the services for which you are billing or that the services represented incident-to services. Caution: "Although most physician practices submit claims electronically, they really should not forget that the certification language on the paper CMS-1500 form still applies," says Jean Acevedo, LHRM, CPC, CHC, senior consultant with Acevedo Consulting Inc. in Delray Beach, Fla. The penalty: Reporting services not performed by the provider indicated on the CMS-1500 is a direct violation of compliant practice operations. If you or your urologists falsify a claim by billing services under another physician's name and ID numbers, you could both face fines or even imprisonment. Looking once again at the back of the CMS-1500 claim form, you will see the following wording: "Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties." "The fact that this statement is printed in bold face type underscores the importance of this," Acevedo says. "One only has to look at the federal and states' False Claims Acts to realize that submission of 'false' information could lead to severe financial penalties of treble damages plus $5,000 to $11,000 per claim."
You're Not Off the Hook if You Use a Third Party Third-party billing companies can also end up in hot water for knowingly billing services for a physician under another physician's name, says Katherine Abel, CPC, billing administrator with Stat Solutions in Nashville, Tenn., and senior instructor for e-learning for the American Academy of Professional Coders. "Regardless of who does the [...]