# NEED QUICK response! Coding Policy...Fraud?



## poxleitner (Sep 20, 2009)

*NEED QUICK response! Coding Policy...*

Hi all,
I have a similar situation that I am seeking help on....I have been trying to locate documentation from the Medicare website regarding split billing wellness and illness, and really what their official guidelines are. We have some controversy on the subject within our facility and administration is trying to push a policy on us that I don't feel comfortable following, hence I am searching for documentation basically to prove that they are incorrect in asking us not to split bill medicare patients and in the event they come in for a wellness and an illness is addressed we are to code only an illness visit that day. Here is what is says word for word....do any of you disagree with this?

In accordance from guidance we have received from the IMA, Brown's Consulting, Noridian Medicare and Karen Newton, Provider Educator for Noridian Medicare we are establishing the following guidelines.




WELLNESS/ILLNESS CODING

MEDICARE: If a patient is being followed for an ongoing condition ie; hypertension, diabetics or medication refills to treat an ongoing condition, this visit will be coded as an office call. If patient is receiving a female exam (Q0081-G0101) and meets the 7 out of 11 requirements, this can be billed in addition to the office call (99211-99215 est-99201-99205 new) with appropriate modifiers.

If a patient comes in for a wellness visit and a problem is found this also will be coded as an office call (exam) codes (99211-99215est 99201-99205 new).

Note: Medicare patient will not receive a split bill for wellness and illness (99381-99387 new-99391-99397 est).

If the patient comes in and is not being followed for a medical condition and no problems found then we code as a preventative service exam (99381-99387 new or 99391-99397 est). At this point the nurse or physician should inform the patient that this visit will be non covered by Medicare guidelines.

Medicare does not consider preventative visit as a covered service, therefore a GY modifier should be used stating we understand it is a statutory exclusion, not a medical necessity issue. Statutory exclusions do not require an ABN to be signed.

MEDICAID: If patient is treated for a wellness & an illness, the wellness visit is what should be coded if over 21 years of age. For patient under 21 years of age, we can split bill as per Medicaid guidelines. Sports physical can be coded as wellness at the wellness price as per Medicaid guidelines; we have established special charge codes for these. 

COMMERICAL-SP: For commercial insurance we can bill split visits as described in the CPT book as well as from information from the IMA. 
It is my understanding that when you are billing a medicare patient for an illness and a wellness on the same day that you have to deduct your illness charge from your wellness charge example:
99397 197.00
99213 63.00
total billed to patient would then be:
99213-25 for $63.00
99397 for $134.00
IS this correct and where on the medicare website can I find this?
Also I have a note that is similar...
here are my findings within it...
the patient was clearly in for a wellness exam, during this exam the Dr. performed a pap/pelvic, however he did not meet MCR guidelines on his pelvic exam with the criteria of 7 of 11 elements therefore I don't feel I can appropriately report the G0101 code, also the Dr. performs a joint injection to the shoulder (20610), if I try and carve out for the shoulder pain I would get a 99212, but he performed an injection for the shoulder pain therefore I was only going to code the 20610.....heres my dilemma, does the shoulder injection need to be reduced from the wellness exam?
here are my examples of prices and scenarios but not sure which one is correct and need to find MCR documentation to support my decision:
99397 reg price 197.00
G0101 reg price 35.00
Q0091 reg price 40.00
20610 reg price 70.00

should I go with:
20610 for 70.00
Q0091 for 40.00 (deducted from 99397 price)
99397-25 for 157.00
(G0101 not codeable due to lack of documentation therefore not deducted from the 99397)

OR:
20610 for 70.00 (deducted from the 99397 price)
Qoo91 for 40.00 ( deducted from the 99397 price)
99397-25 for 87.00

Thanks for all your help and if any of you have direct links to the Medicare website that explains coding regulations that would be great, also your input on the policy above would also be appreciated!
Thanks again
Ang, CPC


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## LLovett (Sep 21, 2009)

I disagree with the carve out of a problem visit from a well care but I am not under Noridian so I can't really speak to that. WPSMedicare has described the carve out as only services that are "normally provided" during a well care visit. Which would be pap/pelvic and breast services that are covered by medicare. A problem visit is not normally included in a well care, joint injection is most certainly not normally included. These would be billed at the regular rate in additon to the well care codes.

I completely disagree with the policy they have put forward. This is just a way to get paid from medicare for a service that is not covered. If the intent of the visit was for a preventive visit then that is what should be billed. Just because the patient has other issues does not mean the preventive service was not done. 

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Top of page 40.

Hope this helps and good luck,

Laura, CPC, CEMC


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## mitchellde (Sep 21, 2009)

I agree with Laura, Just because pre-existing conditions were discussed/examined/tested for, does not make the encounter anything more than a preventive visit.  This is the very essence of a preventive visit, to take inventory if you will.  The AMA had an excellent article on their website a few months back regarding the split visit issue.  They too stated that preventive is discussing/examining the patient and all their pre-exisitng conditions, if the patient expresses a symptomatic issue that can be address in the context of a preventive encounter and is minor in nature then they advised the split encounter, but they cautioned that the office visit should not be more than a level 2 encounter, that anything higher than that would indicate a more severe problem or ill patient and it would be illogical to subject that patient to a preventive exam and the physician would be unable to get a good baseline on such a sick patient.  It made sense to me!


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## RebeccaWoodward* (Sep 21, 2009)

I agee also but for all intents and purposes....20610 is a good example since I don't consider this to be a reason to discontinue a physical exam.

This is how the "carve out works".....

*The physician may charge the beneficiary, as a charge for the non-covered portion of the service, the amount he/she has established as the charge for the preventive medicine service, less the amount that would be owed by Medicare and the patient for the covered visit. In this example, the physician normally bills $200 for a full preventive service. His/her charge for the 99213 is $53.29, the Medicare fee schedule amount.

Service                                    Procedure           DX code     Fee
Preventive Exam                               99397                 V70.0      $146.71
Medically Necessary Exam                   99213                 250.00     $53.29  


The physician may collect $146.71 from the beneficiary for the preventive service ($200 less $53.29) plus the 20% coinsurance of $10.66 for the covered visit. The patient is responsible for $157.37, and Medicare would pay $42.63.*

As for you scenario....I would select:
99397 reg price 197.00
G0101 reg price 35.00
Q0091 reg price 40.00
20610 reg price 70.00

should I go with Scenario 1
20610 for 70.00
Q0091 for 40.00 (deducted from 99397 price)
99397-25 for 157.00
(G0101 not codeable due to lack of documentation therefore not deducted from the 99397)

If you have performed 20610 based on your LMRP or LCD, then it should be paid based on medical necessity.  I would not deduct the $70 (20610)from the PE.  I would deduct the $40 (Q0091) if you are performing this within Medicare's guidelines (based on medical necessity) which would leave a balance of $157.00

http://www.medicarenhic.com/providers/pubs/Preventive Services Billing Guide.pdf

Page 35


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## poxleitner (Sep 21, 2009)

Thank you both for replying, I was beginning to wonder if anyone would!!!! What you said about the policy makes me feel better that I am thinking correctly, and thank you for your direction on my coding scenario. Now it's just a matter of convincing administration that they need to take a step back and really look at what they are asking us to do.  On another note, if a coder chooses to follow this policy either out of ignorance or not, what could be the ramifications of such in the event of an audit? And what about the physician that is employed by the facility, not a private practice? I've spent numerous hours reading and researching fraud, abuse, neglect, ignorance and it seems as though it comes down to the coders and the physicians in the end, policy or no policy.
Thanks again,
Ang...CPC


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## RebeccaWoodward* (Sep 21, 2009)

CMS definition:

*Fraud* is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in unauthorized payment. Keep in mind the attempt itself is fraud, regardless of whether it is successful. 

*Abuse* involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. 

The real difference between fraud and abuse is the person's intent. Both activities have the same impact: they detract valuable resources from the Medicare Trust Fund that would otherwise be used to provide care to Medicare beneficiaries.

Fraud is punishable...abuse is often fined.  Abuse should not be viewed lightheartedly; however, people do make mistakes.  If you recognize your mistake(s) and implement ways to prevent future offenses, this does weight in your favor in the event you are questioned by Medicare.


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## LLovett (Sep 21, 2009)

*Ignorance of the law is no excuse, right?*

If it is wrong, it is wrong regardless of the why (be it on purpose or lack of knowledge) and you can get in trouble. The difference between fraud and abuse is intent. My personal opinion is based on this policy, there is intent there so it is past the abuse stage. They have researched the issue and made a decision to bill Medicare for services that are not covered in a way that will get Medicare to pay for them.

How much trouble, if any, a coder would be in for this type of situation I really don't know.

Rebecca,

I guess we will have to agree to disagree on the carve out! If there is enough documentation to support a problem visit in addition to a well care I don't see how you would carve that out since that service is in addition to the well care, not part of it. 

Laura, CPC, CEMC


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## RebeccaWoodward* (Sep 21, 2009)

Not the first time we have disagreed Laura.


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## RebeccaWoodward* (Sep 21, 2009)

http://www.wpsmedicare.com/j5macpartb/departments/claims/_files/b_carveout.pdf


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## LLovett (Sep 21, 2009)

Rebecca,

I do not understand Medicares logic on this one at all. My stance on the carve out is based on the fact if you reduce the preventive visit charges and bill a problem visit you are in essence billing Medicare for a non-covered service in a way to get paid. 

If the same services were provided on 2 different days you would bill the full fees, if they are done together and you carve out you are hiding part of the non-covered service in the covered one. 

I agree and understand financially it is better for the patient. I just don't see how it is any different than other non-covered services.

Just my opinion,

Laura, CPC, CEMC


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## RebeccaWoodward* (Sep 21, 2009)

I do understand your view, Laura, and this may be why some physicians are requesting the patients to reschedule their PE's and choose to address the "problem" that is present. I think Medicare developed this "carve out" rule so that the beneficiaries would not be subjected to unfair monetary liabilities.  If a physician chooses to treat a "problem" at the same time as the wellness exam, it does make sense that some of the history, exam and MDM would be credited to the problem oriented visit...there is a portion of the visit that is not dedicated solely to the wellness exam.  As a result, Medicare created a "window" of medical necessity for their liability.  I don't necessarily agree with all of Medicare's rules, guidances, etc, but if it's in "black and white", I follow those guidelines. I don't want to compromise abuse.  I know what's correct...I know what can be billed...therefore, we have to put it to paper. Senior citizens are being encouraged to report fraud/abuse.  I just don't want to be on the receiving end of an audit

http://www.smpresource.org//AM/Template.cfm?Section=Home


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## donnareese (Jul 1, 2014)

*Medicare wellness and modifer 25*

So how do we manage the provider that wants to bill for the wellness and a new diagnosis with a separate E&M with a 25 modifier?


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