Wiki New Patient OV with a procedure

[rmooney1114]

Hello, here is my scenario. A provider sees a new patient, the reason for the visit is to remove a wart and there is nothing else wrong with the patient in order to warrant a separate E/M to be billed with the procedure. The new patient E/M (99203 for example) has a higher RVU than the wart removal procedure. Can the provider elect to bill the E/M instead of the procedure just to get the higher RVU's...
Please provider any references to information on this topic if possible.
Thank you

 

[Pathos]

Good morning!

Good question, and this is one I see often. When selecting a code, remember to pick the one which best describes what happened during the encounter, and not focus on which code gives the provider the higher RVU (which could result in a False Claim). Billing a different code just to get higher reimbursement sounds like upcoding and is a big deal for CMS and OIG.

Was the visit a problem visit with issues the provider needed to treat and manage? Was there a specific procedure the provider performed (remember the small E/M bundled into any procedure).

In the example you are giving, I would be cautious in billing the lesion destruction with a M25 and 9920x, since there is not enough Significant, Separate E/M (again based on what you are sharing) to warrant an E/M code.

I'm really glad you're asking, since this is a topic where providers (and coders) can get into big trouble if they're not careful.

Hope this is helpful!

Sources:

Noridian Modifier 25
CMS talks about Upcoding

 

[rmooney1114]

Thank you, your response was very helpful. My reason for asking was that we recently had an outside audit by insurance company and the biggest issues were E/M with procedures and the fact that a separate E/M was not warranted. Those have since been corrected, but then we were "advised" that since an E/M has a higher RVU, that the coders can bill for the E/M instead of the procedure. Personally as an auditor, I am not comfortable with that because as you stated that is inflation and fraud, and its with intent, because you are doing just to increase revenue... I wanted to get feedback from others to see what everyone's thoughts were on this.. I appreciate your feedback, it was very reassuring.
Thank you