Ethics Issue?

elysia.york

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I work for a billing company, and one of the clinics that I code for has recently started to perform a new procedure in the office. Prior to beginning this, the office manager emailed me regarding the suggested coding that was provided by the device manufacturer. In my professional opinion, this code was not fitting AT ALL, and I suggested that they use an unlisted code. I explained this in every way I knew how, and the manager/doctor refused to listen. They performed this procedure for the first time on Monday, and sent me the note yesterday. I then emailed the office manager again and explained that we CANNOT use this code, and asked if she wanted me to proceed with the proper, unlisted code. She then stated that they wanted to use the coding recommended by the manufacturer.

I feel extremely uncomfortable submitting this claim that I know will be fraudulent. The office even made the procedure note documentation match the CPT code that they are wanting to use, when in all reality it was not what was done. I explained to my employer that I would be putting myself (certification) at risk by knowingly submitting false claims and I was not going to do that.

What would you do to "cover yourself?"


Elysia York, CPC
 

JCaillouet

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I'm unsure of the other options but the first thing is to Document, Document, Document.

If you can print the email communication and save a HC of the email on file that will also help you.

Waiting on others to respond here.
 

mitchellde

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I would be concerned when you state the "office made the procedure note match the description" . Because the office does not make a procedure note the provider does this. A provider should never use a cut and paste note for a procedure. So if I were to look in your charts for all procedures with that CPT code attached then your saying I would see word for word the exact same note? That is very disturbing if it is true.
From a coders point of view you code from documentation, however if you know something like has indeed occurred then it is wrong. Providers must dictate a unique note for each patient and each procedure.
 

thomas7331

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Does your organization have a compliance officer or process for reporting compliance concerns? (They should if they don't already.) Ideally, that is the best way to 'cover' yourself - if you report the concern and it is reviewed by your organization, then they make the decision and take responsibility for it at that point. In the absence of such a process, I agree that retaining documentation of your communications with your employer is essential to show that you have made your concerns clear to them.
 

TThivierge

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Unlisted Code

Hi

Physician should always do notations first then add proper CPT code. Unlisted CPT codes are frowned upon cause no RVU credit and most insurance companies will not reimburse unless send the notations with it so they can find a very simililar CPT code. By the way what was the clinical procedure? Are you sure a CPt code does not exist..did you check the index in the back of CPT to locate a better CPT?
 

TThivierge

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It is the Vivaer procedure. https://aerinmedical.com/professional/

The office (manager and doctors) want to use the code 30117, which was suggested by the rep. I searched every way I know how and there is nothing that is fitting. Please, if you have any thoughts, feel free to share!
Hi EY

The CPT code 30117 is fine. Is it for both nostrils or one..use proper modifier 50 or RT or LT per claim line. I' d better use that CPT then a unlisted code. Just make sure doc dx. code is medically necessary or appropriate.

Emails sent to manager is a good way to do the CYA. Just saying:)

Lady T
 

mitchellde

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I honestly do not see any problem with the 30117 code either.. I am curious as to why you feel it is inappropriate.
 

lori mitchell

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Hi,
I'm not the original poster of the question, but I wouldn't think CPT 30117 would be appropriate if there is no intranasal "lesion" involved. From what I read on the Vivaer site, they are using heat to reshape the intranasal anatomy, such as to widen the nasal valves. If a lesion is being destroyed, then 30117 might be appropriate, but if there's no actual lesion but rather a reshaping of anatomy to achieve better airway flow, then I would not advise 30117.
 

mitchellde

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you have a point.. it really would depend on the operative note and the reason for the procedure . but if they have a prewritten op note specifically for the procedure and not for what was actually performed there will be no way to really know would there. That is why I questioned that part of the original post. we look at the documentation all day long but if it has been specifically written to match the parameters of 30117 then that would be the code the coder would naturally select.
 

elysia.york

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you have a point.. it really would depend on the operative note and the reason for the procedure . but if they have a prewritten op note specifically for the procedure and not for what was actually performed there will be no way to really know would there. That is why I questioned that part of the original post. we look at the documentation all day long but if it has been specifically written to match the parameters of 30117 then that would be the code the coder would naturally select.
They issue is that the providers are not removing/destructing any lesions. On top of that, the techniques listed in the CPT lay description are surgical excision, cryosurgery, or laser surgery - all of which are not the same as the Vivaer (low temp radio frequency energy).
 

mitchellde

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again you must code by the note the providers sign. If that note indicates a lesion destruction and matches the description for a given procedure then that is how you have to code it. Knowing that something did or did not happen and having a written operative note are completely different things. code by the note. that is all you can do. If the note does not match any current procedure code then use an unlisted code and refer to the closest matching procedure code for the payer.
 

rjh977@vc

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I DO NOT AGREE WITH BILLING 30117 FOR THIS PRODUCT/PROCEDURE FOR THE REASON THEY ARE STATING TO USE IT. . THEY ARE NOT REMOVING ANY LESIONS-THEY ARE CREATING LESIONS WITH THE WAND TO REDUCE SWELLING INSIDE THE NOSE, THE SAME THING THAT CODE 30801 DOES. IF THEY WERE REMOVING NASAL POLYPS, A CYST OR MUCOCELE, OR AN ULCER OF THE NOSE, THEN BY ALL MEANS THE CODE 30117 COULD BE USED. IF WE BILL IT, WE WILL PROBABLY USE THE UNLISTED CODE 30999. HOPE THIS HELPS!!

BECKY HUTCHENS, CPC
 
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