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Thread: Legal Question

  1. #1

    Default Legal Question

    AAPC: Back to School
    I just recently started coding for a small family practice clinic in a small farm town. I have noticed that they try to help out their patients by doing such as performing a pap and documenting a preventative visit but only charging for a 99212. When I ask why, I was told "patient doesnt have wellness coverage and their deductible is very high so only charge 99212."

    I cant help but think this isnt really legal. I dont think they realize that it maybe illegal. They just see it as helping out someone.

    Can someone tell me if this is legal?

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    It is downcoding and is not a good thing to do. They consider that a false claim submitted and there is a federal staute for that. You may not represent to the carrier a service that was not performed. Tell you physician that he can however barter for the patient owed amount. A farm community should have plenty of fresh veges to barter with and some eggs, it is possible he may never need to go grocery shopping again! But seriously barter is a legal mechanism as long as fair market value it assigned to the goods or services (ie no $100 eggs)

    Debra A. Mitchell, MSPH, CPC-H

  3. #3


    Thanks. I think I will spend the weekend finding documentation to show to the providers that this is not a great idea no matter how much they want to help the patients.

    If they were to be audited it would be really bad.

  4. #4
    Join Date
    Apr 2007
    Albany, Oregon

    Default Legal question -

    Hi KP,
    No, we're not allowed to 'not bill' for services rendered/documented.
    It's called under-coding and the rule is in the Federal False Claims Act. It is considered fraud by the feds. Under-coding is considered an incentive to patients to frequent the practice (yeah, I know!). The False Claims Act also covers over-coding, unbundling, waiving co-pays ...
    I'd bet that the law is more fully described in the Federal Register/OIG (office of the inspector general).
    You can remind your docs that we'll be seeing more and more recovery audits and the audits are being performed by private companies, who typically are base paid + incentive paid based on the amount of $$ they "recover"!
    Hope this is helpful

    Michelle, the bartering idea is fabulous!

  5. #5
    Join Date
    Apr 2007
    Columbia, MO


    I am a firm believer in barter, I feel we should value the skills in those in our community more than the money. It is a way of making unemployed people feel useful and eliminates handouts which I am firmly against. I had a business in our community and I used the barter system all the time. I have a new roof on my house, original artwork on my walls that is fabulous, a freezer full of meat, and my car runs great!

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Join Date
    Apr 2007
    Charlotte, NC


    remember one coding rule, if it is not documented it didn't happen......

    but I too like the bartering idea

  7. #7


    Bartering is a great idea!!!! Also, you may want to consider, if you dont have it in place already, financial hardship policy. We started this several years ago and has worked out great. Our patients filled out a form providing the basic financial information and if they met the requirements we would w/o the balance. This is important to document because collecting copays, deductibles etc is the responsibility of the provider as stated in your insurance contracts. Not to collect copays & deductibles you are in violation of the contract.

    good luck!


  8. #8


    Ok, I need someone to direct me where to find some documentation on this. I went to the OIG website. I can find tons of stuff about upcoding etc... but nothing stating you can undercode for private pay patients.

  9. #9
    Join Date
    Apr 2007



    I know this is talking about inpatient but the principal of all patients have to be treated equally is spelled out very clearly and many of the questions and answers apply to both inpatient and outpatient.

    Laura, CPC, CEMC

  10. #10


    Ok after reading that it doesnt seem to be a problem with them discounting private pay patients?

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