Wiki Billing Surgeries without Operatives

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ladusta

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Our billing service does not bill surgeries without the operative to cya from a financial stand point (don't want to miss codes or miscode) and from a liability stand point. We have a physician trying to insist that we code based off a very abbreviated description of the services that he sends us in emails in order to get his billing out faster. He is not consistent with dictating his operatives so I am concerned this will put us in a bad position legally if we were audited.
Is there some documentation we can use to convince the physician that billing without the dictated operative is not smart or legal? I have to have something to back up what we tell him when we reject his request....please help!
 
Give him the CMS guidelines for fraud because if he is getting his procedures coded without the op report and it just happen to be overcoded indicating maximizing of payments, he could be inadvertantly committing fraud.
 
ladusta said:
Our billing service does not bill surgeries without the operative to cya from a financial stand point (don't want to miss codes or miscode) and from a liability stand point. We have a physician trying to insist that we code based off a very abbreviated description of the services that he sends us in emails in order to get his billing out faster. He is not consistent with dictating his operatives so I am concerned this will put us in a bad position legally if we were audited.
Is there some documentation we can use to convince the physician that billing without the dictated operative is not smart or legal? I have to have something to back up what we tell him when we reject his request....please help!
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And why would it not be ok to just tell him that is the requirement of your agency to provide this service to him, regardless of the legal ramifications? Your billing service is allowed to set it's own standards, and one of them is you require the operative report before you will code and submit claims. The reasons you stated above should be enough, he is not consistent with dictation and it could be considered fraud if you were to be billing codes that were not documented. If a provider does not want to comply with your standards, then he is welcome to find a billing service that will do it his way!

Just for documentation sake, if you go to this link on the Medicare website and look at section 4.2.1 it lists the things considered fraud by Medicare:
https://www.cms.gov/manuals/downloads/pim83c04.pdf
 
Thank you for that information. My point of view is that those are good enough reasons and he is welcome to go with another billing service if he disagrees. The business owner on the other hand feels we need something in writing to back up our reasoning to put this argument to rest. Nothing in that section specifically says you cannot bill without documentation already on file. A few points can be made with what is listed but I am going to look for something more black and white just in case.
Personally I don't want the liability. As long as he is dictating regularly, there shouldn't be an issue.

Thanks,
LaDusta
 
Found some great documentation!

The OIG has a recommended compliance plan for billing companies that addresses billing without documentation as a violation of federal and state regulations. This should address the physicians argument!

Thanks for the feedback! have a great weekend!
 
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