Features Masquerade Billing In the ever-changing world of healthcare, the one aspect that should - and needs - to remain consistent is medical coding. by Diane Gonzales, CPC & Jim Stites, CPC As healthcare changes, new codes are developed, current codes are updated and revised, and old codes are done away with. Proper coding plays a vital role in the medical industry and is the main driving force behind payment and reimbursement. Current Procedural Terminology (CPT) codes are numbers given to every service a medical professional or clinic may provide, which includes medical, surgical and diagnostic services. The main goal of having standardized coding is to maintain consistency and uniformity. However, even with set codes having been developed to describe almost every conceivable aspect of the medical professionals practice, there is still a great deal of variance in the interpretation of these codes and the proper use for which they are intended. That being said, there are a number of CPT codes and coding scenarios that lend themselves to a higher incidence of improper coding. CPT Code 98942 Chiropractic Manipulative Treatment (CMT) Spinal, 5 Regions. The code range of 98940-98942 is often seen as office visits’ billed by chiropractors, and like office visits, can be subject to upcoding. Per the definition of the code this treatment is for each of the five (5) spinal regions: cervical-including alto-occipital joint, thoracic-including costovet-erbral and/or costotransverse joints, lumbar, pelvic and sacral. Improper coding comes into play when only one or two diagnosis codes are submitted that only address one or two of the spinal regions. CMT codes must have supporting diagnosis codes to justify the level of the procedure being billed. In other words, if the code definition addresses five spinal regions then the corresponding diagnosis codes on the claim must also address five spinal regions. Just having the five spinal regions listed in the medical record does not warrant the billing of this highest-level code. According to the American Chiropractic Association, more than 31 million Americans experience low-back pain, 1 resulting in Americans spending approximately $50 billion yearly on treatment. 2 Chiropractors have specialized training in detecting and fixing subluxation, also known as a misalignment of the spine. In some health plans, chiropractic care may be specifically excluded or maybe subject to conditions and limitations, thus resulting in creative billing by the perpetrators to obtain insurance reimbursement by circumventing the chiropractic limitation. This type of activity has led to a misrepresentation of the actual CPT code for medical treatment provided. “Alternative", “holistic” or “complimentary” treatments, such as a Total Body Modification (TBM) (known by alternative practitioners as a form of kinesiological testing or muscle testing), are becoming commonplace on medical billings. By using this form of testing it enables a practitioner to discover imbalances, or blockage impairing health and function. TBM is believed to aid in improving and strengthening the mus-culoskeletal system and neurological function for conditions such as chronic low back and neck pain, fibromyalgia and headaches, to name a few. Contact Reflex Analysis (CRA®), a variation of applied kinesiology analyzes the body's structure and physical and nutritional needs. Analyses of the body's reflex points are tested to determine how the body relates to flow of energy and how the body functions. Reflex points represent an organ's specific function. The patient is evaluated with his/her arm outstretched, with the other extended arm of the CRA ® practitioner. Energy is transferred to the muscle being tested of the outstretched arm, weakening the arm to drop. By testing the reflex the practitioner is able to make treatment recommendations. All these therapies have been billed inappropriately using CPT code 98942. Unless a medical record review or an on-site audit is conducted, these types of services go unnoticed and unidentified by Special Investigation Units (SIUs). Data mining for CPT code 98942 and the frequency of the billing should be looked at closely. Remember that just because it is billed as a chiropractic manipulation does not necessarily validate the actual service performed. CPT Code Range 99354 - 99357: Prolonged Physician Services Prolonged physician services involve the total duration of direct face-to-face patient care that is beyond the normal or usual service provided in an outpatient or inpatient setting. Prolonged service codes are intended to be reported in addition to E/M codes when the length of time a physician spends with a patient goes at least 30 minutes beyond what is typical for that service. Prolonged physician services of less than 30 minutes total duration cannot be included as prolonged services because this work is considered part of the E/M visit code billed. Improper coding comes into play when these codes are submitted when the additional time was spent with the physician's staff, when there was no direct face-to-face physician-patient contact or for prolonged time of less than 30 minutes. The patient's medical record must include documentation to support the level of E/M visit billed and the duration and content of prolonged services that the physician personally furnished. For example a physician routinely bills E/M code 99215, which indicates a typical face-to-face time of 40 minutes, along with CPT code 99354. By billing this code combination together, the physician is stating that a minimum of 70 minutes was spent with direct face-to-face contact with the patient. Medical records must support all the time spent with the patient as well as the level of E/M visit being billed. Recently, a provider’s prolonged abuse of CPT code 99354 was flagged in California. The provider s aberrant billing practices were uncovered by an investigation team who found that across three payors, the provider was billing as much as ninety-one hours of procedures between 104 patients per day. This particular case also brings up time-based codes and, in particular, the 8 Minute Rule, which allows for variable billing based on 15-minute increments. The 8 Minute Rule requires that in order to bill for each additional unit of time at least 8 minutes of each unit is spent providing direct service to the patient. For example if a provider renders any 15 minute timed service for 7 minutes or less on the same day as another 15 minute timed service code of 7 minutes or less, and the time spent performing the two services totals at least 8 minutes, then the provider may bill one unit for the service performed for the most minutes. A current and emerging trend in the ENT field of medicine is a catheter based inflatable device (Balloon Sinuplasty) used in the treatment of sinusitis. The Balloon Sinuplasty is a minimally invasive endoscopic surgical procedure, which uses a small flexible balloon catheter. The balloon is inflated to enlarge sinus passageways. The CPT Assistant article published in January 2010 edition recommends an unlisted code 31299. Beginning in January 2011 CPT incorporated three new Category I codes 31295 thru 31297 for the use of stand-alone balloon sinus dilation at the request from the AAO-HNS. Using these Category I codes does not guarantee payments by all carriers. Some carriers designate the procedures as “inves-tigational” or “experimental.” It is critical to accurately document by a descriptive narrative the actual procedure and/or services performed. Keep in mind each carrier makes their own determination based on their own medical policies, and consider contacting the insurance company. Another area to pay close attention to is the unlisted service or procedure codes. An unlisted code is used when the procedure or service does not yet have a listed CPT or HCPCS code. According to the American Medical Association's Current Procedural Terminology coding guidance, “When reporting an unlisted code to describe a procedure or service it is necessary to submit supporting documentation (e.g. procedure report) along with the claim to provide the adequate description of the nature, extent, need for procedure and the time and effort and equipment necessary to provide the service.” Unlisted codes do not include descriptor language nor do they identify the components of a service. With the ongoing changes in healthcare and new technologies, procedures and advancement in medicine, the principles of accurate medical documentation become increasingly important. Documentation and charting standards apply to all clinicians of all professions and specialties. Medical record-keeping is required to record pertinent facts about an individual's health history. A properly documented medical record enables other healthcare providers to follow a provider s plan of care for the patient and, most importantly, contributes to high quality care.
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