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In an earlier Talking Point, we reported that the HHS Office of Inspector General (OIG) announced plans to increase anti-fraud staff and efforts. It only takes a quick glance at the media to see their efforts are exploding. Add to this, nearly all insurers employ in-house Special Investigation Units (SIU) that have now shifted their focus from the arsonist and car thief to the medical provider who commits fraud. Intentional misuse of CPT coding constitutes fraud in both the public and private sectors.
While a greater number of suspected fraud cases are being investigated in both the public and private sectors, you can take steps to avoid this potentially expensive and reputation damaging experience. Below are some risk areas to be aware of and to avoid.
Risk Areas
Most Practice Management seminars are helpful for many reasons and offer practical ideas to grow your business. Some Practice Management companies recommend reimbursement practices that can land you squarely in hot water. Here is a sampling of common practices being devised and promoted to gain reimbursement without regard to proper coding.
Billing an Evaluation and Management (E/M) Code on Every Visit with CMT: In general, it is inappropriate to bill an established office/outpatient E/M CPT® code (99211-99215) on the same visit as Chiropractic Manipulative Treatment (CPT 98940-98943) because CMT codes already include a brief pre-manipulation assessment. There are times when it would be appropriate, but it should not be routine. Examples of when it may be appropriate to bill an additional E/M service would be the evaluation of new patients, new injuries, exacerbations, or periodic re-evaluations. If you are being told that billing an E/M code on every visit is a proper form of billing, it is incorrect. Please refer to the American Chiropractic Association (ACA) website www.acatoday.com, Insurance and Reimbursement, for specific guidance on the proper use of E/M with a Chiropractic Manipulative Treatment Code (CMT).
Billing an Evaluation and Management Code in Place of CMT: In cases where a limited number of manipulations are allowed, DCs are being advised to use an E/M code instead of a CMT code to get around the limit on CMT. This is inappropriate. You are required to bill the code that best describes the service rendered. Pattern software used by many insurers will easily pick up the code deviation and refer that doctor's billings to the Special Investigations Unit (SIU) for fraud investigation. If a business pattern can be established that shows the doctor deliberately changed codes, a direct fraud prosecution can be initiated. This can apply to any code deviation and is not just limited to E/M codes billed with CMTs.
Inappropriately Billing CPT 97140 in Place of CMT: Billing for multiple time-based codes such as several manual therapies (CPT 97140), when a CMT was the only service performed, is inappropriate. You cannot replace a CMT CPT code with another CPT code if the CMT was the actual service performed. Once again, you are required to use the code that best describes the service rendered. In addition, each unit of CPT 97140 describes 15 minutes of office time-it normally does not take 45 minutes to perform manipulative therapy and payers are fully aware of this.
Unbundling: Some providers are requiring a patient to return to the office on the next day to perform a service that would not otherwise be covered, or that may allow higher reimbursement if it is done as a "stand-alone" procedure on a separate day. Insurers respond to this form of coding manipulation by, at a minimum, combining services into bundled coding edits or, at worse, with limits or caps on services for the entire profession.
These are just a few examples of incorrect coding that have come to light recently. The American Chiropractic Association feels it is important to let you know that using these or other questionable practices puts both you and the entire chiropractic profession at risk. Make sure that you use proper coding procedures-intentional acts that misuse CPT codes hurt the entire chiropractic profession and thwart the profession in its ability to fully integrate into mainstream healthcare.
The American Chiropractic Association sponsors two doctors of chiropractic who sit on the AMA CPT and RUC coding committees and are intimately familiar with coding intent. ACA consistently publishes and keeps current on any new codes or changes to previous codes. If you have a coding question, please bring it to the attention of the ACA insurance Relations Department or the ACA Coding and Reimbursement Committee. In addition, you can purchase the ACA Coding Solutions Book by contacting ACA Member Information Services at 703-276-8800.
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