Code Violations : The Common Ways That Health Care Providers Can Defraud The Government

We as Coders and Billers should understand the interaction of the CPT procedural codes and the ICD diagnostic codes. The providers receive payment for their service, whether it is an office visit or an operation in the hospital. All services need to be coded for proper payment.

CPT code 99307: Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem focused interval history, a problem focused examination, straightforward medical decision making. Usually the patient is stable, recovering, or improving.

The Current Procedural Terminology (CPT) codes, are codes a medical biller uses to report healthcare procedures and services. Both medical billers and providers use CPT codes as a way to communicate with insurance companies. Proper coding and documentaition is essential for reimbursement. Proper coding and documentation also makes the difference between full reimbursement and reduced reimbursement or even a denial. Each code that is sent to a payer on a claim, has to have supporting documentation. For example, if a patient is seen for a urianary tract infection and during the visit the patient receives a urianalysis, you would expect to see an order, the correct CPT code, and the results for a urinalysis in the patients chart. I have always

One of the greatest milestones in the United States health system is the use of electronic health records codes to ensure consistency in diagnosis and treatment procedures provided by physicians (Romano & Stafford 2011). The purpose of the case scenario of the sixteen year old female who visits the emergency department is to show how electronic health record coding is done and its impact on health reimbursement. The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) codes are brought out well in the case study showing how they help in ensuring physician consistency in coding diagnosis and treatment procedures for the purpose of health reimbursement.

to standardize the coding systems used to process Medicare claims. This coding system is mostly used to bill for any supplies that have been used, and any injections that have been given. HCPCS codes must be used in order to bill Medicare. HCPCS codes are

This standardized dialect is also pertinent for medical schooling and teaching in addition to clinical research and studies conducted by scholars, scientists, and physicians by providing a valuable foundation for domestic and coast-to-coast operation evaluations. CPT is used to describe doctor’s services, a vast amount of administrative services in addition to operating services executed in medical facilities, treatment care centers, and outpatient divisions. Providing support for clerical duties and functions such as processing medical claims and initiating strategies and procedures for the evaluation of clinical care is another cause of relevance for CPT. The system also meets the need for tracking trends and identifying improvements, plus progression goals and scaling the value of healthcare services received by patients. The CPT coding system provides physicians throughout the United States with a consistent method for classifying and coding clinical procedures which in return provides a more efficient tool for recording and reporting task that were completed. Physicians, scholars and payors, have been dependent upon CPT to interconnect with other fellow associates, patients,

The E/M code's is a big important part in this process. Being a health care professional, using the medical code's. like medicare, medicaid, other private insurance to be reimbursement. If not using the right code, the doctor office, hospital, and urgent care. Will lose a lot of money. So using the right cpt code's insurance companies, office, hospital, and urgent care can be reimbursement correct. Cause CPT code's are formed with 5 digits.

HCPCs is a collection of codes that represents the procedures, supplies, products, and services that may be provided to Medicare and Medicaid and to individuals enrolled in private health insurance programs. HCPCs are necessary for Medicare and Medicaid providers to provide healthcare claims that are managed consistently to get payment. Some of the settings you would use HCPCs codes would be in home healthcare, laboratory services, and dentist.

To define the CPT procedural code which is different from the E/M CPT codes, the procedural codes are a type of medical classification that identifies specific surgical, medical, or diagnostic interventions. These are carried out at time of service by the provider.

HCPCs or Healthcare Common Procedure Coding System is used to represent procedures, supplies, products, and services that are provided to Medicare, Medicaid beneficiaries, and to individuals enrolled in a private insurance program. The setting I think you would use HCPCs codes in are Hospitals and in Doctor's Office. I think that would be a common setting in which you would use HCPCs codes because of everything that goes into each and every procedure. The doctor puts a lot of material into each and every procedure.

The topic of transitioning to the ICD-10 coding system has become a very big issue within the medical practice field. In fact, as of October 1, 2015, all physicians, hospitals, and medical providers are required by the federal government to be in full compliance using ICD-10 coding. ICD-10-CM codes allow for medical providers to provide as much information as possible about the patients state of health and all treatment provided as such. In addition, "The CPT coding system offers doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency (Ama-assnorg, 2015)."

Unbundling codes: Unbundling is a fraudulent practice of submitting separate claims to an insurance provider for services that could fit on a single bill. Providers send separate

Up-Coding Services: Billing of government and private insurance programs is done using a complex series of numerical codes that identify the specific procedure or service being performed. These code sets can include: the American Medical Association’s Current Procedural Terminology (“CPT”) codes; Evaluation and Management (“E&M”) codes; Healthcare Common Procedure Coding System (“HCPCS”) codes; and International Classification of Disease (“ICD-9”) codes. Government health care programs assign a dollar amount it will pay for each procedure code. Up coding occurs when a health care provider submits of a claim for health care services, treatments, diagnostic tests or items that represent a more serious and more expensive procedure than that which actually was performed. Up coding can be a violation of the Federal False Claims Act.

Imagine the following scenario: Mr. Jones, a patient of Dr. Brown’s arrives for his annual wellness exam. Mr. Jones feels great, with no complaints. When he sees Dr. Brown, Dr. Brown spends 15 minutes reviewing his last office note. He listens to Mr. Jones’ heart and lungs, checks his ears, eyes, nose, and throat, palpates his abdomen, and looks at his extremities for swelling. Everything looks fine. Reimbursement for annual wellness visit has a typically billable value of 50 dollars. However, Dr. Brown documents Mr. Jones office visit as an extended visit, not an annual wellness; that visit now billable value of more than 100 dollars. The medical coder submits the bill as documented. This is up coding.

Medicare and Medicaid fraud has some strengths as well as weaknesses. A strength that comes with healthcare fraud is The Affordable Care Act. This act helps to fight health care fraud, abuse and waste (Department of Human Services, 2014). Many laws have been implemented to help commit those people that have been committing Medicare and Medicaid fraud. Per the Center of Medicare and Medicaid services website “The Affordable Care Act increases the federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1 million in losses, establishes penalties for obstructing a fraud investigation and makes it easier for the government to recapture any funds acquired through fraudulent practices” (Department