Proper billing for separate procedures

Ash82

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I have a provider, who is paid by RVU's, and he is wanting to bill out multiple procedures on separate HCFA's. Example, he does two different procedures, and instead of billing both out with 59 modifier on second procedure, he wants to bill out each procedure on separate HCFA. The payment modifiers change how his RVU's are counted. If the procedures are billed out separate, in his mind, you don't have to put the 59, thus giving him 100% value for both procedures. I have looked through CMS guidelines and I don't see anything stating if more than one procedure is done in the same day, that they all have to be billed out on same HCFA. If anyone knows where I can find some guidelines in regards to this, I would greatly appreciate it. The provider is saying it is incorrect to bill them all out on same form, so I just need something in writing from CMS to show him otherwise. Thanks in advance for any help!
 

CodingKing

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Most modern claim systems are smart enough to apply edits across split claims. Multiple procedure edits are per day not per claim form and knowingly submitting claims in away to avoid multiple procedure reductions and NCCI edits would be considered fraudulent billing. I have no idea why physicians come up with these ideas. Do they really think they are the first ones to come up with a ploy like this? Even if it did pay it would be an inappropriate payment and should be reimbursed as soon as possible to avoid a federal false claims act violation.
 
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Ash82

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He's not trying to get around the insurance cutting the 50% reimbursement to the company he works for. He is paid from the company he works for, according to his RVU's. Even if the claims went out on separate HCFA's, I know the insurance would still reimburse or probably even deny the second procedure because it didn't have that modifier, but he would still be paid at 100% of the RVU's for both procedures. He's not doing anything fraudulent, I think maybe I have not explained myself very well.
 
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If these procedures are being done during the same session, then they need to be billed appropriately, all together, on one claim form, with the appropriate codes and modifiers.

By billing each procedure on individual claim forms, the provider is:
1. Misrepresenting the facts - FRAUD
2. Billing for services at a higher level of complexity (If multiple procedure reductions apply and given that the payment reduction logic is built into Medicare's claims processing system, if you're not submitting all of the charges on the same claim form, you're (attempting to) bypass the logic and get paid more than what is deserved) - FRAUD
3. Creating substantially more work to be done by Medicare unnecessarily processing individual claims, when it should have just been one claim - ABUSE
4. Misusing codes on a claim - ABUSE

"Knowingly" submitting includes deliberate ignorance of the truth and reckless disregard of the truth, so no matter what excuse is being made here, the provider will be liable. If it's an issue with RVUs, that's not a problem for Medicare to deal with. The provider needs to take it up with whoever is paying him.

Are RVUs worth more than the penalties he could face from billing incorrectly?
 

CodingKing

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There would be no reason to split it on 2 claims, other than to attempt to circumvent payer system edits (exception would be more than 6 lines on the same DOS).
 

thomas7331

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He's not trying to get around the insurance cutting the 50% reimbursement to the company he works for. He is paid from the company he works for, according to his RVU's. Even if the claims went out on separate HCFA's, I know the insurance would still reimburse or probably even deny the second procedure because it didn't have that modifier, but he would still be paid at 100% of the RVU's for both procedures. He's not doing anything fraudulent, I think maybe I have not explained myself very well.

This actually could be considered fraudulent - in fact, it sounds to me as though he is trying to defraud his employer. He should not be telling his biller or coder to change the process to influence how he is paid. In fact, if changing the billing will cause denials by the insurance company as you say, then that would actually cost his employer even more money. This is not ethical, and I would not participate in this.

If he feels his pay is not being calculated correctly according to his contract, he needs to take that up with his employer, not mess with the claims.
 

Ash82

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I completely agree with what's been said, but does anyone know where I can find in writing from CMS that separate procedures done on same dos by same provider should be billed on same claim form?
 

Ash82

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Thank you again for your reply! I totally agree that you can't always find something in writing, but I always try because if you have something in writing, there isn't much argument the provider can have. Again, thanks for everyone's input.
 

thomas7331

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I agree you won't find anything in writing specifically against splitting the claims because there is no prohibition on this - in some cases it may be appropriate. However, from a payer perspective, I think what you're describing falls under the definition of 'abuse'. Medicaid, for example, defines abuse as 'provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.' Consistently splitting claims or removing modifiers that could cause errors would do just that - it creates extra claims processing and re-work costs for the plans you're submitting to, even if there is no payment error.

Here's a document that contains this info and might be of some help:

https://www.cms.gov/Medicare-Medica...-Education/Downloads/fwa-overview-booklet.pdf
 
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