Wiki NOT billing for all services provided

mullman

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I'm hoping somebody can lead me in the right direction. I'm looking for documentation from CMS or OIG or somewhere talking about fraud/abuse from the standpoint of NOT billing for all services provided and documented. I know that this is also not okay, just cannot find anything to back me up. For instance, seeing a patient for an OV and preforming a small procedure that the provider doesn't feel is justified billing out separately. What are the rules? What are the guidelines? Everything talks about upcoding and billing for services not preformed. I cannot find anything about omitting services preformed. Help??!! Thank you!
 
Can you provide an example of where the provider is billing an office visit instead of a procedure? There can be instances where an E&M is more appropriate based on the documentation, but that would not be the normal. From a compliance point of view there are some questions that come up:

  • Is this service being excluded because the physician does not feel the medical records justify the additional modifier 25?
  • Is there a contractual issue with the carrier?
  • Is the provider just trying to financially give the patient a "break"?

There are many questions and aspects that may affect the outcome of the question, so it may be appropriate to direct this to your compliance officer for additional research.
 
I guess we could include reasons like 1) the provider not thinking the procedure preformed is significant enough to bill, like treatment to one small b9 lesion not justifying billing a 14 lesion code 2) preforming a procedure, very non-invasive, such as a simple milia extraction on one lesion, as a courtesy during an E&M visit.

Thanks.

Can you provide an example of where the provider is billing an office visit instead of a procedure? There can be instances where an E&M is more appropriate based on the documentation, but that would not be the normal. From a compliance point of view there are some questions that come up:

  • Is this service being excluded because the physician does not feel the medical records justify the additional modifier 25?
  • Is there a contractual issue with the carrier?
  • Is the provider just trying to financially give the patient a "break"?

There are many questions and aspects that may affect the outcome of the question, so it may be appropriate to direct this to your compliance officer for additional research.
 
With those examples it would not be "incorrect" to not bill for the procedure. Most likely the provider does not consider the procedure significant enough to level an additional charge and considers it as covered in the E&M. This would be the providers discretion and not a billing error.
 
An aspect of this that also needs to be considered is the prohibition against offering 'inducements' to Medicare beneficiaries - a provider may not offer gifts or free services to patients if this could potentially influence their choice of provider or their decisions to consume other covered services or supplies. There are allowed exceptions to this, as detailed in the publication linked below. If you have specific concerns about this, it would be best for your organization's compliance or legal specialist to review the specifics.

 
Thank you both! Since the provider is not wanting to bill some of these procedures, what type of documentation is required to establish that it is felt not to be significant enough to bill separately? A simple statement stating it's insignificant and should not be separately billed from the E&M? Is this reasonable?
 
An aspect of this that also needs to be considered is the prohibition against offering 'inducements' to Medicare beneficiaries - a provider may not offer gifts or free services to patients if this could potentially influence their choice of provider or their decisions to consume other covered services or supplies. There are allowed exceptions to this, as detailed in the publication linked below. If you have specific concerns about this, it would be best for your organization's compliance or legal specialist to review the specifics.


To this point I wonder if the safest bet is to use modifier 52 or an unlisted service code, especially Medicare claims.
 
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