Wiki Coding Ethics & Legality


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I have a client who insists that I bill Medicare for code pairs that the CCI edits say will never be paid when billed together. I have discussed both the ethics and the extra time involved with the client to no avail. Her attitude is, "If I do it, I should be reimbursed for it, and even if I'm not, I want to report the fact that I did it!"

Should I continue to bill these codes? What are the legal implications?

I would tell your client they need to become better educated about the False Claims Act. Under the False Claims Act (FCA), anyone who knowingly submit, or causes another person or entity to submit, or knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approval of government funds are liable for three times the government's damages plus civil penalties of $5,500 to $11,000 per false claim.

The term "knowingly" means that a person:

1. has actual knowledge of the information;

2. acts in deliberate ignorance of the truth or falsity of the information; or

3. acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.

That is a summary of the Federal False Claims Act, your state should have their own regulations also. Maybe the FCA can scare your client straight. I know of a physician office who not only had to pay back $250,000 in false payments, but also had to pay a very hefty fine of close to $2 million & they lost the right to bill to Medicare, Medicaid, & Blue Cross.
Is this really a false claim or is it that the client does not understand coding guidelines? She is not reporting something she didn't do, but wanting to report something she did do that is bundled with another code. It is a dilemma. I hope someone has some excellent advice on this topic!
There might be some helpful information in the CCI guidelines. The introductory chapters explain why the specific edits are there, why sometimes modifiers are allowed and sometimes not and when modifiers are appropriate. Just an idea...
If the client has been told that the codes are considered bundled per the CCI edits and or she has received denials from carriers for the code combination, then she is acting in disregard, even if it is not to deliberately defraud the insurance company. If she is merely wanting to "report" these codes as performed then why not just enter them in her billing software and write the bundled code off & not submit it to the insurance. Our office does that with services provided by residents without a physician present. The service is still listed on the patient's account for reporting purposes but the charge is written off.
I think the client doesn't understand

I think the client may not understand the concept of bundling.

The fact is that she IS being reimbursed for all she does if procedure A is included in procedure B, the RVUs and reimbursement for procedure B take into account all the work involved.

Would she want you to code for the complex repair of the surgical wound site (she "did" it, after all) even though it's an integral part of the surgery and therefore bundled?

F Tessa Bartels, CPC, CPC-E/M
Thanks for Responses

Thanks for the responses. I will certainly look up the Frauds Act and will also re-read the CCCI Edits language. Both good ideas.

My client understands the concept of bundling but her postion is that she wants to report everything she does, "because I do the work and I should get paid! I don't care what the guidelines say." This applies mostly to procedures in the office but occasionally to surgeries. She does not want us to write these off before submitting to the insurance companies.

I should note that we never get paid for the bundles procedures, but my concerns are threefold: Is it ethical / legal? Is it likely to attract an audit? It affects the revenue we write off and therefore negatively impacts the percentage of revenue collection. This makes me look like I'm not doing a good job in getting claims reimbursed.
legally speaking

If you continue to submit claims to payers, claims that you as a CPC know are fraudulent, you are liable. You better find a new job, contact and attorney or get liability insurance. Read the back of the CMS 1500 claim form. Show it to your physician.