This Practice Paid Medicare $4.48 Million

Do you sign up for email lists and then wonder why you did it? We all do, don’t we?  But, one email I always read is from the Department of Justice that links to a description of actions, settlements and indictments related to health care billing and coding

A few years ago, an Orthopedic practice returned $4.48 million dollars to the Medicare Trust Fund.  Although it is in the public record, I’ve used “The Practice” in place of the name of the group, and inserted my commentary.

1. The Practice certified that it met certain standards related to the “meaningful use” of electronic health records when the practice had, in fact, not met those standards;

Well, this is an obvious no-no.  Not much to say about attesting that you met meaningful-use standards when you didn’t.

2. The Practice knowingly billed for certain claims as “incident to” physician supervision when no physician was present or there was no verification of any physician being present;

Reporting services incident to a physician results in payment at 100% of the physician fee schedule rate.  This is compared to 85% if the services could have been billed directly by an NP or PA.  This is compared to 0% if the service was billed by a staff member without a physician present to supervise. Remember that for billing incident to services, the physician (or NP or PA if billing under their NPI) must be in the suite of offices when the service is performed.  There are many resources on CodingIntel about incident to services. 

3. The Practice knowingly billed for certain claims using Modifier 25 signifying that a separate evaluation and management service was performed even when there was no such separate service;

Can we all agree that when using modifier 25 the E/M service must be separate and distinct?  A separate E/M is more likely but not guaranteed for a new patient or a new problem. 

4. The Practice knowingly billed for certain claims using Modifier 59 signifying that two procedures, rather than one, were billable even when these procedures should have more appropriately been billed as one such procedure;

Using modifier 59 bypasses edits in the claims processing system and allows a surgeon to be paid for a procedure that is a component code of a primary surgery. It should only be used when the second procedure meets the definition in the CPT^® description of modifier 59: “Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

5. The Practice knowingly scheduled patients’ follow-up operative visits from 12 weeks following surgery to 14 weeks in an effort to bill for a separate visit outside the normal Medicare 90 days;

I’m at a loss about what to say about this, except don’t do it.

6. The Practice knowingly used and billed for ultrasound-guided injections routinely even in the absence of medical necessity; and

7. The Practice knowingly billed for certain physical therapy claims using Modifier KX so as to exceed the Medicare cap on physical therapy, despite the absence of medical necessity.

How does a reviewer know if there is medical necessity?  The documentation.  Documenting clinical thinking in a non-templated manner is more difficult using an electronic health record. Everything looks the same. But, documenting the medical necessity for services is critical.

Back to blog