Gastroenterology Coding Alert

You don't have to actually make money to be liable for filing a false claim, according to the U.S. Supreme Court. A recent ruling reaffirms liability under the federal False Claims Act regardless of whether the person causing the submission of false

claims to the government financially benefitted from their actions, according to a press release from the American Academy of Professional Coders.

The case: The court case isn't about medical coding, but the decision affects coders. An appeals court had allowed a lawsuit against California state and local school officials to proceed; those officials allegedly submitted a false claim to the

federal government but did not personally profit from the claim. The Supreme Court said that court case could go ahead.

Michael D. Miscoe JD, CPC, CHCC, a compliance advocate, said, "Since coders are in many cases responsible for code selection as a means of representing the services performed, where the coder makes choices that are incorrect and

designed to 'get paid,' liability can arise if the representations made resulting in payment are knowingly inaccurate.

"As certified coders, the standard of knowledge is not that they actually knew the code was wrong," Miscoe says, "but should have known by virtue of their training and credential. Because of a certified coder's training and credential, the standard

for what such a person 'should know' could potentially be higher."

The False Claims Act applies to federal claims, but it often provides guidance in cases involving state or common law fraud standards.

The takeaway: When you submit claims according to what gets your physician paid, and not to accurately describe the service to the patient, you can be liable. Your gastroenterologist is not the only target for false-claim allegations.

The court case is Wilcox v. United States ex rel. Stoner, U.S., No. 07-1336