General Category > General Questions
Fraud and Abuse - Coda
PMRNC:
--- Quote ---Some relevant points to keep in mind. It is the doctor's responsibility, not yours, to use the ABN when necessary. The biller is not required to examine the patients chart before billing to see if it contains support for the codes submitted to you by the doctor. If you are receiving codes electronically, how can the ABN be included?
--- End quote ---
I gathered he meant that he DOES get ABN, but I wanted to just touch base on something. FROM a NON legal perspective, it is indeed the responsibility of the front office staff in collecting and gathering all relevant information needed for billing purposes. The ABN is one of them. The next level is indeed it is a billers job to KNOW what services an ABN is required. My OM's always send me a copy for my files. If I see a charge that needs an ABN ( ha ha.. no more ABN's for me. no more Medicare! :) ) it's MY job to make sure the staff got one. Again, this is NOT a legal perspective but this is the correct procedures. Billing companies have a choice in offering services, if they contract to do FULL practice management, certain functions indeed are their responsibility. I know this was offtrack.
RichardP:
We do NOT bill anything that is obviously wrong.
... we do NOT bill without an ABN.
gary - I wondered if that was what you meant, based on your wording.
The client is under investigation by the OIG/FBI.
The first link I gave you above adresses exactly that. The OIG has stepped up its investigation of consistently high levels of coding. We have clients who are specialists who consistantly code high, but the chart documentation supports it and they are OK.
Re. the ABN (Advance Beneficiary Notice of non-coverage), for those who might not know: Medicare does not pay for all procedures / services the patient might request and/or the doctor might order. If the doctor does the procedure, and Medicare denies payment, the doctor can not charge the patient for that procedure unless - before the procedure was done - the patient has signed an ABN acknowledging that Medicare might not pay, so they will pay if that is the case. Page 4 at the following link gives more specifics.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf
Note that the language there says You must issue the ABN when: 1.) .... 2.) Medicare usually covers the item or service, and 3.) (the doctor thinks) Medicare may not consider it medically reasonable and necessary for this patient in this particular instance.
Linda - you defined exactly how we operate re. ABN's. We also notify our clients when an ABN is necessary but has not been provided. And, like you, we see that as a service we provide our clients. You said it is a billers job to KNOW what services an ABN is required. In the main, I agree with that. But note in the language quoted above, the pivot point is what Medicare considers medically necessary. It is not just that there is a list of codes we have to memorize where Medicare will not pay (although that list does exist). The list must be made up of those codes that Medicare normally pays, but may not pay in this case because Medicare determines that the procedure was not medically necessary. We have found that it is not always possible to correctly guess when Medicare is going to deny something because it was not medically necessary. So we err on the side of caution.
Note that the ABN is an issue only if the doctor intends to charge the patient for the procedure if Medicare does not pay. If the doctor does not intend to charge the patient if Medicare denies payment, if he is simply going to write off the charge, the ABN is not an issue. That translates into this: if Medicare denies payment for a charge that the doctor has not given us a signed ABN for, we automatically write off the charge, no questions asked. Medicare denied payment, patient was not billed, no question at all of whether there are legal issues involved. The patient is not billed and that ends it.
gary999:
Provided that everything else is perfect, does an abnormal E&M cause concern in a specialty practice?
RichardP:
gary - if you have not yet read through the two links I provided above re. Level 5 coding, it would benefit you to do so. Both links emphasize the point that there is nothing incorrect about coding at any particular level - so long as the documentation in the chart supports it.
That would be the general answer to the question you just asked about abnormal E & M. But what do you mean by abnormal?
gary999:
--- Quote from: RichardP on February 09, 2013, 09:01:01 PM ---gary - if you have not yet read through the two links I provided above re. Level 5 coding, it would benefit you to do so. Both links emphasize the point that there is nothing incorrect about coding at any particular level - so long as the documentation in the chart supports it.
That would be the general answer to the question you just asked about abnormal E & M. But what do you mean by abnormal?
--- End quote ---
We bill exactly what we are given. No more or less. OIG is implying we should have known better since the practice is mostly level 5's.
Edit to add: We do NOT code the charges.
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