Wiki Fraud question

[nastar2208@gmail.com]

Good Afternoon,
I have a question about compliance, Our Nuclear Med and Ct department have been putting in orders but our Epic system Auto Auth certain HMO referrals.
When our tech perform the services the cpt code may change ,so they have been correcting the cpt code and sending the claim to our HPS department to verify and process everything before our claims are submitted to the insurance company. Our utilize management team is stating by us changing the cpt on the referral after it Auto Auth we are conducting fraud.... Now I know bill the wrong cpt code and preforming another cpt is fraud , so I am just trying to clarify this referral issue.

Need Help Please . .

 

[csperoni]

Is your tech performing a service that the provider did not order? Or did the provider order in words (like CT of abdomen and pelvis without contrast) and your system assigned an incorrect CPT for authorization purposes? Or did the provider order a test and during the performing there was a medical reason to perform additional testing (which should be decided by a provider)?
Fraud is intentionally giving false or deceiving information to get payment for services when you should not, or higher payment than you should receive.
It is very unlikely this situation is fraud. But depending on why this is occurring, you should probably work out the logistics of authorizing the correct testing performed.

 

[nastar2208@gmail.com]

Thanks a Million .. That's what I though we need to work with our EPIC regarding the Auto Auth. I didn't think it was fraud because we are not up coding . The issue was the doctor may order CT of Abdomen and thing when the tech perform the service it may change to CT of Abdomen with contrast.

 

[csperoni]

Thanks a Million .. That's what I though we need to work with our EPIC regarding the Auto Auth. I didn't think it was fraud because we are not up coding . The issue was the doctor may order CT of Abdomen and thing when the tech perform the service it may change to CT of Abdomen with contrast.

I would question who is determining the patient needs a contrast exam? I don't code for radiology, but pretty sure a tech can't determine that and the order would need to come from a clincian (MD, DO, NP, PA, CNM, etc). If the original ordering physician WANTS a CT abdomen with contrast, they must ORDER a CT abdomen with contrast. I think the radiologist is allowed to order additional testing if at the time of service it is needed, but not the tech.

EDIT: I was curious about this, so looked into it. Found this great AAPC article. Apparently sometimes, in certain locations, the radiologist may order additional testing. But most locations, most situations, the treating physician must order the test with contrast.

https://www.aapc.com/blog/38745-follow-the-rules-%E2%80%A8of-diagnostic-test-%E2%80%A8orders-for-radiology/

 

[luvbuix]

sounds like you need to educate your providers to be more specific. some payers may have an issue with that if there was ever an audit. if they have smartphrases in their orders try building both CTs in to that.