Is This Fraud?

dballard2004

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I have a dilema that I need some advice from my fellow coders. On a recent coding audit for one of my clinics, the auditor discovered that the clinic was not documenting veinpunctures when patients had labs drawn at the clinic. There was no documentation of the veinpuncture whatsoever. As it turns out, our company policy states that the sites do not have to document the veinpuncture unless there is some sort of problem with the blood draw. When I spoke to our clinical complience department about the policy, it was stated to me that the lab work can't be done without the veinpuncture being performed, so the veinpuncture is implied. Clearly the policy needs to be changed, but my problem here is that these claims went out the door to Medicare. I have researched Medicare criteria and can't find any documentation requirements for veinpunctures. I have a very uneasy feeling about this because I feel that we are billing Medicare for services we can't prove we provided because of no documentation. Before I proceed with a fraud investigation and notify Medicare, I want to make sure that I am doing the right thing here. Is there some guidance from Medicare that I missed about veinpunctures? I want to make sure that I am on target here. Thanks.
 

btadlock1

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I have a dilema that I need some advice from my fellow coders. On a recent coding audit for one of my clinics, the auditor discovered that the clinic was not documenting veinpunctures when patients had labs drawn at the clinic. There was no documentation of the veinpuncture whatsoever. As it turns out, our company policy states that the sites do not have to document the veinpuncture unless there is some sort of problem with the blood draw. When I spoke to our clinical complience department about the policy, it was stated to me that the lab work can't be done without the veinpuncture being performed, so the veinpuncture is implied. Clearly the policy needs to be changed, but my problem here is that these claims went out the door to Medicare. I have researched Medicare criteria and can't find any documentation requirements for veinpunctures. I have a very uneasy feeling about this because I feel that we are billing Medicare for services we can't prove we provided because of no documentation. Before I proceed with a fraud investigation and notify Medicare, I want to make sure that I am doing the right thing here. Is there some guidance from Medicare that I missed about veinpunctures? I want to make sure that I am on target here. Thanks.
I'm inclined to agree with your compliance dept. on this one - if the lab order and results are documented, and it was a blood lab, it should be implied. It's interesting that the venipuncture isn't mentioned anywhere on your lab reports, though - usually, they have some sort of info about how the sample was obtained, which would have given you the documentation you need.
You might request that they add something to the lab requisition (like a check box) to indicate where/how the sample was drawn from, just to be on the safe side. I really don't see Medicare coming down on you for this, but it never hurts to be cautious. ;)
 

btadlock1

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I take that back...

If you have Palmetto, you should definitely require documentation of the venipuncture:
"Venipuncture Documentation - Palmetto
Palmetto, our Medicare Administrative Contractor (MAC), requires that supporting documentation for venipuncture clearly reflects that the venipuncture has been performed. Lab results alone are not sufficient to document that venipuncture was performed."
http://www.medfusion.net/templates/groups/3443/5020/2011-08 Compliance Newsletter.pdf


I also found some Highmark CERT data that talks about 36415: https://www.novitas-solutions.com/cert/pdf/errors/2009/jul-sep-a.pdf

CMS's claims processing manual, doesn't seem to mention it - so you should check with your MAC (https://www.cms.gov/manuals/downloads/clm104c16.pdf):
"60.1 - Specimen Collection Fee
(Rev. 1, 10-01-03)
B3-5114.1, A3-3628
In addition to the amounts provided under the fee schedules, the Secretary shall provide for and establish a nominal fee to cover the appropriate costs of collecting the sample on which a clinical laboratory test was performed and for which payment is made with respect to samples collected in the same encounter.

A specimen collection fee is allowed in circumstances such as drawing a blood sample through venipuncture (i.e., inserting into a vein a needle with syringe or vacutainer to draw the specimen) or collecting a urine sample by catheterization. A specimen collection fee is not allowed for blood samples where the cost of collecting the specimen is minimal (such as a throat culture or a routine capillary puncture for clotting or bleeding time). This fee will not be paid to anyone who has not extracted the specimen. Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test (e.g., glucose tolerance test), the series is treated as a single encounter.

60.1.1 - Physician Specimen Drawing
(Rev. 1, 10-01-03)
HO-437, A3-3628, B3-5114.1
Medicare allows a specimen collection fee for physicians only when (1) it is the accepted and prevailing practice among physicians in the locality to make separate charges for drawing or collecting a specimen, and (2) it is the customary practice of the physician performing such services to bill separate charges for drawing or collecting the specimen."
 

cheermom68

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The lab order and results only imply that the service was performed but not where. The patient could have went to an outside lab or the local hospital to have the lab drawn.
It is also a risk issue if not documented. What if the patient claims that they were injured by the lab draw? Without documentation of when, where and by whom it was done, you would have no defense.

LeeAnn
 

losborn

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I'm a fraud investigator

No - this is not fraudulent. It could be characterized as poor practice to not include the VP in the record, but the existing lab reports verify it happened.
The bottom line, however, is that there is no overpayment here. Without billing for it, there are no charges that would defraud the payer, therefore no concern about fraudulent billing.

Does this make sense?

Lin
 

cheermom68

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labs

I disagree, an existing lab report only supports that a lab was drawn but not where. The labs may have been drawn at that site or they could have been drawn at the local hospital, an outpatient lab etc. Remember, not documented, not done. If the blood draw is not documented in the record then the 36415 should not be billed.
LeeAnn
 

LLovett

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So what would constitute fraud Lin?

I'm curious since it seems to me that they are knowlingly billing for a service they can not prove happened as it is represented on the claim.

The line between fraud and abuse is basically crossed when you know something wrong is happening and you continue to do it. Which is what is happening here, they know the services are not documented yet they continue to bill for them.

I really don't see how this practice is any different that having scrubbers that automatically add modifiers or additional codes to get around edits. Just because you did labs doesn't mean you did the draw. I used to be in an office that home health would drop off specimens they obtained at the patients home on a daily basis.

It is always interesting to find out how other facilities are handling things,

Laura, CPC, CPMA, CEMC
 
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