I have a dilemma and I'm hoping you can give advice. Today I was asked for a critical care code. I was told we had a patient at the office for 6 hours and they had him hooked up to ivs. They have him 2000 ml saline, etc. when I started to read the guidelines for a critical care code I saw where it said the Dr had to be present the entire time, couldn't attend to any other patient... Here's the dilemma! The Dr was only in the office for maybe 2 hours out of the 6. When I mentioned this to the doctor he said code it as if he were there because he was basically on the phone back and forth with the office the whole time. He said he was going to write up the chart as if he were there. I know this is illegal and unethical. I go to my executive director with my concerns and she basically blew me off. This hasn't been billed yet. It is scheduled to be billed tomorrow with the rest of today's encounters. I know if I bill this knowing its wrong it comes back on me too. What should I do?
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Wiki Am needing some advice
- Thread starter jkesler
- Start date
Pam Warren
True Blue
I think I need more information, but saline hydration alone probably won't constitute critical care, whether a doctor was present at the time or not. If you read the criteria in CPT for critical care, you'll see that the patient must be critically ill with either severe organ impairment or failure or acute trauma, and high probability of imminent or life-threatening deterioration (if no treatment were to be provided), with high medical decision making documented. I'm not sure what was going on, read the note thoroughly, and ask yourself that question, first.
The provider left the office? As in drove off? No, you can't bill for that, regardless of what he says or documents. If he was in the same building, he'd have to be continuously either at bedside or on the phone/discussion regarding coordination of care of that patient only. If they insist on billing the entire six hours and it's truly not warranted, calmly remind them that they're asking you to commit fraud and that from an ethical standpoint as a certified coder, you simply cannot agree to do such a thing. Do you have a compliance officer? Alert them of the situation. Clearly and carefully document this situation, what happened, what you were asked to do, what was said, and what you did (or didn't do) and keep a copy at your home. If those kinds of requests continue, I'd start looking for another job. Good luck.
The provider left the office? As in drove off? No, you can't bill for that, regardless of what he says or documents. If he was in the same building, he'd have to be continuously either at bedside or on the phone/discussion regarding coordination of care of that patient only. If they insist on billing the entire six hours and it's truly not warranted, calmly remind them that they're asking you to commit fraud and that from an ethical standpoint as a certified coder, you simply cannot agree to do such a thing. Do you have a compliance officer? Alert them of the situation. Clearly and carefully document this situation, what happened, what you were asked to do, what was said, and what you did (or didn't do) and keep a copy at your home. If those kinds of requests continue, I'd start looking for another job. Good luck.
The patient came to the office as a walk in patient. The doctor was at the hospital working when the patient came in. The doctors medical assistant contacted the doctor who then instructed his medical assistant to start treating the patient. On the encounter form a 99215, 99291 x 1, 99291 x 9, 5 hrs of iv therapy, 4 bags of saline, 1 bag of dextrose/water, an influenza A & B, a CMP and a CBC were marked. The treatment was started on the patient at 9:47 am and the doctor did not arrive at the office until sometime after 2 pm. The patient left the office at 4:30 pm. When I mentioned the critical care couldn't be billed for the full 6 hours he told me to do it that way because he was basically calling back and forth the whole time checking on the patient. He then told me he would put in the chart that he was there the whole time. I know this is illegal and unethical. We do not have a compliance officer in the normal sense. It would be our executive director.
mitchellde
True Blue
Here is the kicker... you are a physician office.. you cannot bill for any services that take place when the provider is not in the office. When you use his NPI number in box 24J as the render/supervising provider, that means he is physically present to render the service or supervise the service. Since this clearly does not meet the incident -to definition of an established problem with an established plan of care it definitely cannot be a patient the MA can initiate. There needed to be a physician in the office to see this patient. Also I have never had an MA that was IV certified. The only personnel that can start an IV is an MD an RN or an IV certified LPN, I have never heard of an MA being able to obtain an IV certification. There are more issues here tan the billing in my opinion.
Pam Warren
True Blue
Hoo boy. I don't want to touch this with a 10-foot pole!
Deb, you are absolutely correct. The patient situation and the treatment provided is not appropriate for incident-to, and it's definitely not critical care.
What would I do?
Go to CMS and look up the incident-to rules. Show them to your provider and executive director and explain that you violated those rules. Then explain the critical care guidelines and that this situation doesn't meet those, either. Explain again the concept of fraud. For your own records, document their response. Unfortunately, you can't even bill the IV Tx if there was no MD in the suite. (not to mention they should have sent the patient right to the ED in the first place).
If these services are billed out, and you knowingly participated in the fraudulent billing, you can be held liable. Maybe you should find another job, because it sounds like this particular group has no concept of compliance and they are putting you (not to mention the patients) at significant risk. Again, good luck.
Deb, you are absolutely correct. The patient situation and the treatment provided is not appropriate for incident-to, and it's definitely not critical care.
What would I do?
Go to CMS and look up the incident-to rules. Show them to your provider and executive director and explain that you violated those rules. Then explain the critical care guidelines and that this situation doesn't meet those, either. Explain again the concept of fraud. For your own records, document their response. Unfortunately, you can't even bill the IV Tx if there was no MD in the suite. (not to mention they should have sent the patient right to the ED in the first place).
If these services are billed out, and you knowingly participated in the fraudulent billing, you can be held liable. Maybe you should find another job, because it sounds like this particular group has no concept of compliance and they are putting you (not to mention the patients) at significant risk. Again, good luck.
Wow!!!! Debra and Pam have given you the same advice I'd of given you!! I'm floored that after you explained everything to the doc and your administrator that they still want this service billed as if the doc was there and that he says he will document the chart as such!!!!
My only piece of advice- get your résumé updated and start sending it out- ASAP!! I left a longtime employer for something similar when I realized they had no interest in being compliant, sad but I like chocolate and Pepsi too much and I hate the color orange( that's the color of our prison jumpsuit here in Pa)!!
Best if luck to you!!
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Peter Davidyock
Expert
I will echo the get your resume ready guidance.
A physician gaming the system like that is a dangerous person to work for.
An admistrator dismissing the issue is uneducated and most certainly not a leader.
There are compliance and ethics boards available. Keep that in mind.
The very first thing I would do is request completed documentation. If the physician seriously wants to submit this force him to lie by signing a fraudulent critical care note. Remember that time spent must be documented for critical care. I would hope he would not sign a 6hr cc note for pos 21.
If he does you have all the answers you need.
It's time to put your big person pants on.
A physician gaming the system like that is a dangerous person to work for.
An admistrator dismissing the issue is uneducated and most certainly not a leader.
There are compliance and ethics boards available. Keep that in mind.
The very first thing I would do is request completed documentation. If the physician seriously wants to submit this force him to lie by signing a fraudulent critical care note. Remember that time spent must be documented for critical care. I would hope he would not sign a 6hr cc note for pos 21.
If he does you have all the answers you need.
It's time to put your big person pants on.
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Does this physician do this on a regular basis? Or is this a one time incident? I would remain calm. You may think the executive director blew you off, but she may have not shared what her course of action was. That information may not be something she can share with you.
Send a letter or an email and document the conversation that you had with the executive director and keep a copy. if this turns out to be an ongoing problem, there are several courses of action that you can take.
This is a tough one, hang in there.
Nancy Price, CPC
Denver AAPC
President 2013