99223

tlewis76

Contributor
Messages
10
Location
Florissant, MO
Best answers
0
Good Morning,

I have a doctor that wants to have 99223 on all of his initial hospital patients. He has requested that once coded and if the level is 99222 or lower that we send it back so he can change it to make it a 99223. I am not comfortable in doing this it seems unethical to me. Am I over reacting? Any advice would be appreciated.
 

Chelle-Lynn

True Blue
Messages
729
Location
Modesto, CA
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0
No, you are not overreacting. What your provider is essentially doing is considered a type of medical billing fraud. The provider is required to bill the appropriate level of service based on the actual service rendered. By billing one type of code level each time without the support of or based on the medical records means that he is "coding" just to get paid and not for the services rendered. Sending a corrected claim later does not negate the fact that the original claim form is being sent with unsubstantiated billing.


This fraudulent practice has been coined as “upcoding” or "downcoding" since your doctor is required to assign the correct CPT code to each service performed. Medical billing fraud is any attempt to fraudulently obtain an incorrect payment from an insurance carrier. This type of coding is illegal and fraudulent. Any provider who intentionally codes incorrectly is breaking the law.

I would suggest reviewing federal and state laws with your provider showing how this practice is unethical. I am sure that your physician is honestly unaware of the complexity and ramifications of this practice. Good luck! :)
 

gost

Guru
Messages
245
Location
Charleston, WV
Best answers
0
Agreed and...

No, you are not overreacting. What your provider is essentially doing is considered a type of medical billing fraud. The provider is required to bill the appropriate level of service based on the actual service rendered. By billing one type of code level each time without the support of or based on the medical records means that he is "coding" just to get paid and not for the services rendered. Sending a corrected claim later does not negate the fact that the original claim form is being sent with unsubstantiated billing.


This fraudulent practice has been coined as “upcoding” or "downcoding" since your doctor is required to assign the correct CPT code to each service performed. Medical billing fraud is any attempt to fraudulently obtain an incorrect payment from an insurance carrier. This type of coding is illegal and fraudulent. Any provider who intentionally codes incorrectly is breaking the law.

I would suggest reviewing federal and state laws with your provider showing how this practice is unethical. I am sure that your physician is honestly unaware of the complexity and ramifications of this practice. Good luck! :)


I would add to this since it sounds like your provider is suggesting changing their documentation to meet the higher level. Changing documentation after the fact requires addendum documentation. Too many addendums on multiple charts can be a red flag for auditors. More importantly, this suggestion sounds like the provider may be documenting services which may not have been provided. That certainly is fraud. Also, assuming the services were provided and just not documented in the original note, the provider needs to keep in mind that the higher level of service must be supported by medical necessity. Providing services that are not medically necessary is also grounds for exclusion.
 
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