We read recently of a radiation therapy provider that agreed to pay more than $3.5 million in a CMP (civil monetary penalty) settlement with the OIG (Office of Inspector General).
According to the settlement, the company submitted claims for radiation and oncology services that:
- Used incorrect CPT codes and service dates
- Weren’t provided
- Didn’t include sufficient documentation to support service necessity
- Were “unbundled”
- Contained “incomplete documentation”
Fraud or abuse
In general, the AMA says, medical billing errors fall into one of two broad categories: fraud or abuse.
The AMA’s “Principles of CPT Coding” offers definitions of the terms: Fraud “involves intentional misrepresentation,” while abuse means “the falsification was an innocent mistake, but nonetheless representative.”
Common coding miscues to avoid
The organization also lists some common medical-coding errors to avoid:
- Unbundling codes: the AMA says providers should use the single code “that captures payment for the component parts of a procedure.” Don’t unbundle to increase payments.
- Upcoding: consequences for this can be “severe.”
- Failing to check NCCI edits before reporting multiple codes
- Failure to append appropriate modifiers/appending inappropriate modifiers
- Overusing modifier 22-increased procedural services
- Improper use of time-based infusion and hydration codes
- Improper reporting of injection codes
- Reporting of unlisted codes without documentation: if you have to use an unlisted code, include proper documentation.
To avoid those kinds of mistakes, contact an attorney experienced in representing clients in Medicare and insurance audits, as well in crafting compliance plans.