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Is this Fraud?

  1. #1
    Default Is this Fraud?
    Medical Coding Books
    I'm having a discussion in one of my medical management groups; and this question came up:

    Can one physician sign off on a patient for another physician without billing for that date of service?

    EX: Dr. Smith sees a patient May 5, 2010 and discharges them, Dr. Stein sees the patient on May 6th -- looks over the paperwork and signs off on it. Dr. Stein is not billing for May 6th. patient was D/C May 5th.

    Where can I find this on CMS?
    Karen, CPC
    Physician Chart Auditor

  2. #2
    Location
    White Plains, NY
    Posts
    123
    Default Why would the second doctor sign anything?
    Regardless, if there is no payment request (bill), there is no fraud.

    Lin
    CPC CFE

  3. #3
    Default
    Thanks Lin.

    Why is this not on the CMS' website?
    Karen, CPC
    Physician Chart Auditor

  4. #4
    Location
    White Plains, NY
    Posts
    123
    Default
    I couldn't say, but this is not a medical issue.
    This is a legal determination. If there is no $$ paid out, who is defrauded?

    Lin
    CPC, CFE

  5. #5
    Default
    I understand.

    Thanks.
    Karen, CPC
    Physician Chart Auditor

  6. #6
    Default
    I think a little more background is needed. I don't think it is fraud because if I am understanding the situation there would be no medical necessity for the visit after the discharge.

    This happens here sometimes and was actually addressed in a lunch time learning E/M session by WPS Medicare.

    The patient is discharged then for whatever reason, ie nursing home doesn't have a bed, patient can't get a ride, etc they end up staying another day or longer. The doctor has already said they are ok to leave so there is no medical necessity for them to be seen after this. If the doctor decides to stop in and see that they are still fine then that is great patient care but not a billable service and therefore not fraud to not bill. On the other hand if they see them and something is wrong and there is medical necessity to support the doctor being there after the official discharge day then you should bill for that service. Not billing for it would be seen as an error. Doubt they would go the fraud route because it is in their favor but it is still wrong.

    Just my experience for what its worth,

    Laura, CPC, CPMA, CEMC

  7. #7
    Default
    Thanks Laura
    Karen, CPC
    Physician Chart Auditor

  8. #8
    Location
    White Plains, NY
    Posts
    123
    Default fraud definition
    Please bear in mind that the term "fraud" is very specific. A CPT code by itself can be either rightly or wrongly applied, and the claim can still be fraudulent. For instance, a provider performs perfectly acceptable E/M visits, but bills under another physician's NPI - that is fraudulent.
    I was not commenting on the appropriateness or inappropriateness of the code, only with respect to fraud.

    I am a Medicaid fraud investigator.

    Lin

  9. #9
    Smile
    Quote Originally Posted by katmryn78 View Post
    I think a little more background is needed. I don't think it is fraud because if I am understanding the situation there would be no medical necessity for the visit after the discharge.

    This happens here sometimes and was actually addressed in a lunch time learning E/M session by WPS Medicare.

    The patient is discharged then for whatever reason, ie nursing home doesn't have a bed, patient can't get a ride, etc they end up staying another day or longer. The doctor has already said they are ok to leave so there is no medical necessity for them to be seen after this. If the doctor decides to stop in and see that they are still fine then that is great patient care but not a billable service and therefore not fraud to not bill. On the other hand if they see them and something is wrong and there is medical necessity to support the doctor being there after the official discharge day then you should bill for that service. Not billing for it would be seen as an error. Doubt they would go the fraud route because it is in their favor but it is still wrong.

    Just my experience for what its worth,

    Laura, CPC, CPMA, CEMC
    I agree with Laura on this. WPS-Medicare did have an FAQ based on your scenario/question:

    Q3. I provided the final discharge instructions on Tuesday. However, the patient did not leave the hospital until Wednesday. I did see the patient on Wednesday. How do I bill for this?
    A3. Report the discharge day management service for the date of the actual visit, even if the patient is discharged from the facility on a different calendar date. The service on Wednesday is a subsequent hospital visit code when the documentation supports the code and the level of service and medical necessity of the service.

    Keep in mind that like Laura stated, "medical necessity" must be apparent for the subsequent visit if the physician had the face to face with the patient after the discharge date. Hope this helps.
    Evangelina Frohna, CPC, CEMC

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