Wiki Office visit or procedure is it a choice?

[catharine]

Good Morning all,

I have 2 physicians that are arguing with me. Here are the scenarios:
1) A patient comes in for a scheduled cystoscopy and then the Phys spends 45 min they want to only bill the 99215 not the procedure.

2) Pt is receiving pelvic floor therapy in office. Since most insurances will not pay for this my doctors are billing for the 99112 and the 51784 for the first 4 visits then instead of billing the 90912 they want to bill an office visit (99215) since they are dictating and discussing with the patient for 40+ minutes the results and progress of the treatment.

Can physicians choose too bill for an office visit instead of the office procedures in order to get higher reimbursement? they also want me to help them create a template for the pelvic floor therapy that will meet the level 5 criteria. is there documentation somewhere that showed that doing the above is not right or is it a gray area.

Thank-you

 

[jkyles]

Hi there,

Just for starters the claim the doctor submits must match the documentation for the service they performed. So if their documentation says "I did this service on this date" and the claim says "Actually I did another service on this date" the doctor will have to send that money right back to the payer.

Scenario 1 - If the 45 minutes are for a separate E/M visit that is not related to the service the doctor might be able to report both the service and the visit. But they can't just apply the service time to an E/M visit.

Scenario 2 - Doctors absolutely can not, ever, do this. Again, the code reported has to match the service. In addition, deliberately submitting a different code because the service performed isn't paid is a great way to get in trouble.

If they aren't actually doing an E/M visit no amount of creating templates will make it OK.

They need to look at their contracts with their payers because I'm pretty sure that they include clauses about submitting accurate claims. For Medicare claims, the back of the CMS-1500 has a pretty clear statement that the doctor certifies the accuracy of what they're submitting. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1500.pdf

I recommend that you and your doctors read this as well: https://www.cms.gov/Outreach-and-Ed...Products/Downloads/Fraud-Abuse-MLN4649244.pdf.

Good luck.

 

[catharine]

Thank-you. This is what I've been telling them but they like to twist and push the envelope.

Appreciate the help and the link.

 

[jkyles]

Thank-you. This is what I've been telling them but they like to twist and push the envelope.

Appreciate the help and the link.

Sure thing. I should have included this model compliance plan because it gives a lot of information on problematic behavior with citations. https://oig.hhs.gov/documents/compliance-guidance/801/physician.pdf