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Fraudulent Bill?

  1. Default Fraudulent Bill?
    Medical Coding Books
    I am hoping some of you can weight in with your thoughts. A patient is seen by the bariatrics surgeon for a lapband adjustment and an office visit. The billing office sends a bill to the payor for both E/M level office visit and lap band adjustment. The payer denies the lapband adjustment as being inclusive in the payment for the office visit. The lap band has a higher gross charge than the office visit.

    What are the ethics revolving around only billing the higher level charge (lap band adjustment) and not the E/M level office visit?

    My thought is that this has illegal written all over it.

    Any thoughts or links on this topic would be greatly apprciated.

    Thank you!

  2. #2
    Location
    Fresno Chapter
    Posts
    59
    Default
    Quote Originally Posted by anlagrange View Post
    I am hoping some of you can weight in with your thoughts. A patient is seen by the bariatrics surgeon for a lapband adjustment and an office visit. The billing office sends a bill to the payor for both E/M level office visit and lap band adjustment. The payer denies the lapband adjustment as being inclusive in the payment for the office visit. The lap band has a higher gross charge than the office visit.

    What are the ethics revolving around only billing the higher level charge (lap band adjustment) and not the E/M level office visit?

    My thought is that this has illegal written all over it.

    Any thoughts or links on this topic would be greatly apprciated.

    Thank you!
    Hi,
    I understand your concerns in this matter but if the doctor performed the actual services and it is documented correctly you shouldn't have to worry about any ill feelings with sending out your claims. In this case I would put it on the documentation and send a corrected claim accordingly. If the documentation is more E&M based then send in the visit. If the patient came in and the office visit is very minimal and you have a extensive note on the adjustment then truthfully the office visit should never have been billed since the patient only came in for the adjustment. We all know that there are doctors out there that document only what they think is needed so I would review the documentation and code accordingly. If it happens to be the adjustment that should have been billed, it won't be because it costs more it will be based on what the can be supported by the doctors documentation and you should feel comfortable with that.
    I hope that helps

  3. #3
    Location
    Alexandria, LA
    Posts
    518
    Default
    What are you coding for lap band adjustments? There isn't a code for that. AMA said in April 2006 that adjustments "after the global period may be accounted for in the evaluation and management coding."

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