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Downcoding? Is it fraud ?

  1. #1
    Default Downcoding? Is it fraud ?
    Medical Coding Books
    i Know upcoding can lead to fraud, but what about this situation in downcoding ?

    Lets say you work in an ASC, booking comes across as a modified radical mastectomy, CPT CODE 19307, A medicare patient. Worker at ASC says this is not an approved ASC procedure. Calls physician office back , physician office says use 193O3-Mastectomy-simple. 3 days later patient has surgery. Dictation comes across and operative report says Mastectomy , modified radical, which is cpt code 19307, which the coder knows that 19307 is not an approved code.Supervisor says code it as 19303, CODER does not want to code it as 19303, coder says 19307, no it wont get paid but its the procedure code what physician did. ASC has to take a loss. Supervisor say no , if it was coded as 19303 , as per booking , and its undercoded thats ok, no fraud

    Well I disagree,I think it would be fraud because they did a procedure that they should have not done and looking for a code to get paid something. Am I right on this ?
    Last edited by codedog; 10-20-2011 at 04:56 AM.

  2. #2
    you code what was done and dictated in the op report and thats that..... anything else is fraud. If you want to make sure then speak to the surgeon and bring your books and show the surgeon this is why we have to code it this way.

  3. Default
    YES!!! I agree w/ ASC coder....

  4. #4
    they say it is not fraud, anyone can you please direct me to a link that shows down coding is also fraud thanks

  5. #5
    Hartford, CT
    One of Medicare's definitions of fraud is "billing for services that were not performed". If you have provided a service you are obligated to bill for the services that were done. Coding a lesser procedure to get paid is still fraud based on medicare's definition. For more information go to the OIG's website, they have information on physician compliance and training. You can also research on the CMS website under their MLN section.

  6. #6
    thanks will do

  7. #7
    check your private message

  8. #8
    Columbia, MO
    At the very least it is a false claim submission and comes under the false claims act, to knowingly put incorrect information on the claim for the purpose of reimbursement. It is not just downcoding here it is using a code that you know is covered to cover up the fact that you performed a procedure that the payer considers a hospital only procedure. There are so many problems with this, what if there are problems with the patient recovery, your facility is wide open for malpractice issues here. There are reasons the payer has determined this to be a non ASC allowable procedure and you have agreed to abide by those determinations. No you may never down code or up code any procedure on any claim at any time.

    Debra A. Mitchell, MSPH, CPC-H

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