Gastroenterology Coding Alert

Texas GI physician was found guilty in $16M fraud scheme.

When your gastroenterologist certifies a home health plan of care, do you scrutinize the documentation? In most cases, the answer is “probably not.” But one Texas GI physician was recently found guilty for making it look like home health care services were performed and certified, even if they weren’t.

The background: On Oct. 7, a federal jury in Texas found gastroenterologist Yolanda Hamilton, MD, guilty of conspiracy to commit healthcare fraud and conspiracy to solicit and receive healthcare kickbacks, as well as false statements.

The Department of Justice had alleged that Hamilton and others “conspired to defraud Medicare by signing false and fraudulent plans of care and other medical documents, and submitting fraudulent claims to Medicare to make it falsely appear that the patients of Hamilton and her co-conspirators qualified and received home-health services under Medicare,” according to a press release from the DOJ about the case.

In reality, the DOJ notes, Hamilton and her associates actually paid patients to recertify for home health services even when those services weren’t medically necessary — and in some cases, they weren’t even rendered. The GI physician is also said to have charged home health agencies illegal kickbacks, and Hamilton ended up billing about $16 million in fraudulent and false claims to Medicare, according to the Oct. 7 DOJ press release.

Consider These Tips to Avoid the Same Fate

If your GI practice often gets involved in certifying home healthcare services, make sure you stay on the straight and narrow with the following tips.

Initial cert: For initial certification of a home healthcare plan — and recertification of a patient who hasn’t received Medicare-covered home health services for at least 60 days — report G0180 (Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per certification period). The HCPCS code G0180 will certify the patient for 60 days of home healthcare.

Check on agency: In addition, the agency providing the home healthcare should be enrolled with Medicare to provide skilled services to Medicare patients. For instance, your clinician might order a home healthcare nurse to administer total parenteral nutrition (TPN) intravenously, monitor the patient’s weight and vital signs, assess the effects of medications prescribed, take lab specimens, and add supplements to the TPN mixture if necessary.

Your GI physician can dictate these orders to the agency via the telephone. He will also create goals for the patient, as well as expectations of what progress should occur as part of a required plan of care for the patient.

Know the recert code: If the plan extends beyond the initial period of 60 days, you should instead report HCPCS code G0179 (Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per re-certification period) for recertification of the care plan. This can be the same plan that was previously certified or a modification of it.

Determine when to transition to care plan oversight: Once the plan of care has been certified, any coordination of care done with the home healthcare agency should be reported as care plan oversight. For example, your physician may decide after a week to change the patient’s medications and increase the number of nurse visits. This modification is part of the care plan oversight and can be billed with code G0181 (Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more).

Warning: Don’t bill these codes unless the gastroenterologist has direct contact with the home healthcare agency servicing the patient. Otherwise, your office is not justified in using the codes.

Resource: To read more about the case, visit  www.justice.gov/opa/pr/texas-physician-convicted-16-million-medicare-fraud-scheme. To find out more about which patients qualify for Medicare’s home healthcare benefit, visit  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Home-Health-Benefit-Fact-Sheet-ICN908143.pdf.