Are You Paying Attention to Your Coding Practices? You Better Be!

November 28, 2012

Many physicians were once content (and a few still are) to let their coders select their codes for billing purposes.  At a time when enforcement authorities have some heavy-duty technological weapons for identifying improper billing, physicians can no longer avoid learning the billing rules applicable to their services.

We all know that billing and coding rules are complicated but learning them is not nearly as difficult as, say, getting though medical school. Ultimately, if your name is on the claim, you are responsible for the other information on the claim as well.  Does your documentation support your codes?  Do your diagnosis codes support your procedure codes?  Are the modifiers correct?  If you’re a physician and you don’t know the answers to these questions, take the time to learn this stuff.  Everyone makes mistakes but disregarding rules that you should know could ultimately be deemed abusive or even fraudulent billing.

Consider this recent settlement related to the improper use of Modifier 25. The United States Attorney’s Office for the Northern District of Georgia announced back in September that it has reached a settlement with a Georgia oncology group, which agreed to pay $4.1 million to settle claims that it violated the False Claims Act by billing Medicare for evaluation and management services that were not permitted by Medicare rules. This oncology group is one of the largest private oncology practices in the country with 27 offices.

In the announcement, Sally Quillian Yates, United States Attorney for the Northern District of Georgia, said, “Health care providers should be on notice that if they inflate their billings, we will aggressively seek to recover not only the overcharges, but also significant penalties under the False Claims Act.” Ricky Maxwell, Acting Special Agent in Charge, FBI Atlanta Field Office, stated: “The FBI continues to do its part in ensuring that federal funds appropriated to Medicare are spent appropriately and today’s settlement is an example of those efforts. The FBI urges anyone with information related to overbilling or fraudulent billing of our Medicare programs to contact their nearest FBI field office.”

The civil settlement resolves the United States’ investigation into the group’s practices relating to billing for evaluation and management (E&M) services on the same day as a related procedure. Generally, providers are not permitted to bill both E&M services and a related procedure on the same day under the Medicare program’s regulations. In specific circumstances, providers can avoid this prohibition by submitting their claims marked with modifier -25, which tells Medicare to pay both the procedure and the E&M service. Here, the U.S. Attorney’s Office alleged that the oncology group applied modifier -25 to claims that did not qualify for its use, leading to overpayments by Medicare.

Because of widespread abuse of the use of modifier -25, the U.S. Department of Health and Human Services, Office of Inspector General has targeted the use of modifier -25 in its yearly work plans. The yearly work plans outline the current focus areas of the OIG and lead to increased scrutiny by the OIG of those areas. The focus on the abuse of the use of modifier -25 was prompted because prior OIG work has shown that improper use of the modifier resulted in inappropriate payments to Medicare providers.

This resolution is part of the government’s emphasis on combating health care fraud under the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services, in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $9.2 billion since January 2009 in cases involving fraud against federal health care programs.

Please note that the claims settled by the settlement agreement are allegations only; there has been no determination of liability.

This and other similar settlements should send a clear message to health care providers across the country that they will be held responsible if they misrepresent the services they bill to Medicare, even unintentionally. This current administration is very serious about cracking down on healthcare fraud. It’s a known fact that the government gets a return of $17 for every $1 spent on combating healthcare fraud. So pay attention to your coding practices doctor!

Reed Tinsley, CPA is a Houston-based CPA, Certified Valuation Analyst, and Certified Healthcare Business Consultant. He works closely with physicians, medical groups, and other healthcare entities with managed care contracting issues, operational and financial management, strategic planning, and growth strategies. His entire practice is concentrated in the health care industry. Please visit

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