Wiki E/M code vs procedure code

[ellistneal]

I need a reference to show to my provider my point but first I need help with the following scenario:

My provider performed wound care to a patient using code 15271 which is paid less than an office. The provider now wants to use an office visit charge instead of the procedure to get paid at a higher rate. There are no other conditions/diseases addressed at this visit. From my understanding this is considered fraudulent and up-coding. Please inform me if I am right or wrong.

Also, please provide a reference to back me up. Thanks

 

[jkyles]

Hi there, every claim must accurately reflect the work the provider performed. Submitting a different code just because it pays more is at the very least an abusive form of billing, which could lead to allegations of fraud, investigations and so on.

Medicare has a handy booklet on fraud and abuse that mentions submitting incorrect codes to increase revenue. https://www.cms.gov/Outreach-and-Ed...Products/Downloads/Fraud-Abuse-MLN4649244.pdf

You can also show the signature of physician/supplier section on the back of the CMS-1500, which requires the provider to attest that they're aware of and followed the rules on each claim they submit. https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1500.pdf

 

[ellistneal]

This is great! I'm very appreciative your feedback.