# When is it considered Fraud?



## mgutirob (Feb 27, 2015)

I have a very serious question and I am hoping that I can get a great answer. I reviewed a providers documentation and his notes supported a level 99203 for a new patient. I was instructed to down-code the service to a level 99202 because Medicaid will not reimburse for a 99203.  I took this to my superior and informed her the issue and she told me that I needed to down-code the service so that the claim would get paid. I told her that I code based on what the documentation supports and not just so the provider will get paid. I consider this fraud and I need to know how other coder's would view this.  Any input would be most helpful


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## mitchellde (Feb 27, 2015)

Medicare will pay 99203.  And yes down coding is not legal.  The codes on the claim must be supported by the documentation.  You should be able to find more information either from just google physician down coding or from the OIG website.  
I am curious as to where you found that medicare does not pay for 99203.


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## teresabug (Feb 27, 2015)

MediCAID is the payer. They are their own nightmare and I don't envy you for having to deal with their own "rules" on what they pay....

Yes you code based on documentation and medical necessity.

Tell your superior that providers get fined for down coding just as much as overcoding. Been there personally with an internal med dr who refused to bill according to guidelines because he didn't want his patients that had a 30% ov copay to "have to pay so much". He overutilized the 99213 code and went under review and got fined for not coding 99241's.

It is probably best if your supervisor re-reads the 1995 and 1997 documentation guidelines for affirmation; keep following the guidelines. Best of luck!


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## mitchellde (Feb 27, 2015)

Ok but even Mecicaid does not encourage fraud.  I am wondering if this is a Medicaid HMO or other similar type of medicaid payer that sets a cap on reimbursement regardless of the level charged.  It just does not sound right that they would consider a level 3 non covered.  I worked for medicaid and while difficult every rule had a reason and many were badly interpreted.  I would look into your state Medicaid regulations to obtain more information.  I cannot imagine that if a patient truely required a level 3 or higher service Medicaid would try to encourage the provider to perform less than adequate care by not covering basic office visit levels.


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## vjst222 (Apr 9, 2015)

I am going through this same thing, except with Emergency Medicine. I am a newbie so I don't feel like it is my spot to say anything. I have been coding for over 8 years but just started this job for ED physician coding. They are billing level 99285 over and over again, when I went through the chart notes I was not getting the same level of service....and since I am the "newbie" I am wrong. I don't know what to do.


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## Daniel Rowden (Apr 9, 2015)

You never down code and you never over code. You must always code for the services rendered. If the physician doesn't understand that then explain to them the repercussions of not following the rules. It can lead to fines and more severe penalties of OIG exclusion from Medicaid and Medicare which can easily ruin the physicians career.

It is knowingly submitting fraudulent claims which puts you in the realm of Federal False Claims Act... It is a really slipper slope. 

"31 U.S.C. ? 3729. While the False Claims Act imposes liability only when the claimant acts
?knowingly,? it does not require that the person submitting the claim have actual knowledge that the
claim is false. A person who acts in reckless disregard or in deliberate ignorance of the truth or
falsity of the information, also can be found liable under the Act. 31 U.S.C. 3729(b)."

http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/smd032207att2.pdf


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## vjst222 (Apr 10, 2015)

Daniel

 I appreciate your response. I am in need of an auditor to verify a few things for me before I take this to my supervisor. The problem I am having is... I am new to this job. I have been there a week. I am not new to coding. I have been coding physician services for 8 years. I feel like I don't have much ground to stand on when it comes to levels of service. I really need someone to help answer a few questions for me ( I might be the one in the wrong, that is why I need to verify things first)

 I'll just ask the questions here and hope someone will respond. In the Examination area of an audit. They have where you can use the 1995 or 1997 guidelines. If I use the 95 guidelines are there any specific "bullets" to follow for body systems? I know in the 1997 guidelines there are specific bullets for each body system you have to hit.
 Here is what I am seeing when I look at my Drs charts. They are talking about 12 body systems, which is good, but they are not hitting every/not even 2  bullets in that body system. Example is the NECK body system. The DR dictates " neck is normal" but talks nothing about the Thyroid. Therefore he didn't complete that body system. 
 Does the 1995 guidelines get that specific when it comes to the bullets? Because when I look at an auditing form it doesn't even talk about specific bullets to hit. 

Thanks or any help

 Valerie


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## FTessaBartels (Apr 28, 2015)

*95 guidelines*

VR Coder
The 95 guidelines are NOT specific but DO differentiate between body areas and organ systems.

NECK: normal  ... would be a body area

For the 95 guidelines:
Problem focused exam:  a limited exam of the affected body area or organ system
Expanded PF exam: limited exam of affected body area or organ system and other symptomatic or related organ system(s)
Detailed: extended exam of the affected body area and other symptomatic or related organ system(s)
Comprehensive - general multi-system exam (8 or more organ systems) or complete exam of a single organ system

The body areas are:
Head/face
Neck
Chest, Breasts, Axillae
Abdomen
Genitalia, Groin, Buttocks
Back, Spine
EACH extremity

The organ systmes are:
Constitutional (vitals, appearance)
Eyes
Earns, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic / Lymphatic / Immunological


You may use whichever guideline is most beneficial to the physician, but you must stick to ONE guideline (95 or 97) per patient visit.

Hope that helps

F Tessa Bartels, CPC, CEMC


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