Wiki Billing for Consultations

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stephmf415

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Is it appropriate to bill for consultations when a new patient comes to an urgent care facility and has a pcp? I really know the answer I'm just making sure I'm not going crazy.
 
Of course you know the answer is "no." The scenario described fails the three Rs test for consultation services -- the PCP has not requested an opinion of the urgent care provider. The urgent care provider is simply providing care to the patient in lieu the patient seeking care from his/her PCP. This is done for the convenience of either the patient or the PCP -- or both.
Sometimes it helps to have someone confirm what we already know to be true.
 
Of course I know...however my managers are trying to convince that this is ok. I am not coding for the facility, but I do "quality control" on all coded claims, make corrections when needed and submit. They want ALL new patients coded as consultations, no exceptions. I have stated I will not do this and was told not to come to work on Monday if I don't comply.
 
Billing consults in UCC

Hi Stephanie,

I'm so sorry to hear that your managers told you not to show up for work if you don't comply with their request that all new patients to UCC are billed with 9924- & 9925- (consult) codes.

Is it possible for you to take this issue to a higher authority - the compliance manager or someone like that?

If so, I would present a copy of the Consult Guidelines from the E&M section of the CPT manual. You might also research the CMS or BCBS websites for further information & authority.

It might be that your managers do not know the difference between a "consultation" and a new patient. The managers may not be knowledgable enough to make that determination.

Good luck to you!
pat kidd, cpc, cgsc
 
My coworker and I have both shown them what is considered a consult and they told us to stop wasting our time and do our job. We have discussed it numerous times. I see more and how crooked this place is...we don't even have a compliance manager. This is my first job after becoming CPC certified and its becoming a nightmare.
 
unfortunately your only option is to do what you know is correct and accept that they may fire you. I suggest beginning your job search now. I have had these same persons come to my classes and will argue with me over the correct way to code and bill things, they do not listen to reason. I am afraid there is probably nothing you can do short of reporting blatant fraud billing practices to your attorney general.
 
I am definitely getting my resume out there. I am just tired of being ridiculed for doing my job right. They want us to code for higher reimbursement rather than what was done. They also want us to code 87798 when a pt has a rapid flu test rather than 87804 because it pays more.
 
I truely hope you are not coding that way, regardless of what your superiors want. I walked away from a very high paid position for the very same thing.
 
I recommend reading, if you haven't already, the OIG's compliance plan.

a. Coding and Billing.
A major part of any physician practice’s compliance program is the identification of risk areas associated with coding and billing. The following risk areas associated with billing have been among the most frequent subjects of investigations and audits by the OIG:

• Billing for items or services not rendered or not provided as claimed; 12 • Submitting claims for equipment, medical supplies and services that are not reasonable and necessary; 13 • Double billing resulting in duplicate payment; 14 • Billing for non-covered services as if covered; 15 • Knowing misuse of provider identification numbers, which results in improper billing; 16 • Unbundling (billing for each component of the service instead of billing or using an all-inclusive code); 17 • Failure to properly use coding modifiers; 18 • Clustering; 19 and • Upcoding the level of service provided.20

There is an example provided for each infraction above. I would read the entire regulation and share this with those in charge. Do your providers know this is being encouraged? Are they aware of the ramifications of what will happen when this (And it WILL in time) be exposed? Turning a blind eye will not hold up in court. I wish you the best!

https://oig.hhs.gov/authorities/docs/physician.pdf

And if they need real examples...

https://oig.hhs.gov/fraud/enforcement/criminal/index.asp
 
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Newspaper clips

If none of the other great suggestions posted here work for your superiors, then I would suggest printing out newspaper clippings of other medical professionals who tried to cheat the system and were busted for fraud. I am sure there are articles out there with the same scenario. Seems like every other day here there is some type of medical frauder caught.

That should get their attention, but if not; then report and leave. If you do not, and say nothing you could end up losing your certification. So not worth it.

I too, went through this when I worked for a DME company. I tried numerous times for them to see clear of incorrect coding and they refused telling me to drop it and they ended up taking my file away. I was the appeals and denials coordinator, but I was also a CPC-A at the time. I and another employee reported them to Medicare for fraud. Within a year, they were arrested in the 2010 Medicare Strike-Force Sweep across the nation. Just this year, court proceedings were finalized and both owners found guilty on numerous counts of fraud.

Keep your head up and stay positive. Believe you are doing the right thing when they will not listen even when you have shown them verifiable proof. Even if they don't take your word for it, they could call someone and verify the information.
 
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