Medicare Compliance & Reimbursement

Question: Our office uses an outside biller. In reviewing some of the EOBs, I've found instances when the biller is adding services that the physician hasn't marked on the superbills. For example, a patient came in for a follow-up appointment (99213) and she received an injection of Toradol (J1885). The biller added 90772 to the claim as well. Is it OK for her to do this?

Answer: Stick to the adage, "If it's not in the documentation, you cannot bill it."

When billing, you should never add codes for services that you don't have documentation for. If the outside biller does not have access to the physician's note, or the physician did not document a particular procedure or service code, the biller should not add it to the claim.

In all probability, the physician did perform the 90772 (Therapeutic, prophylactic or diagnostic injection...) service, but without documentation to support the code, the biller cannot make that assumption. This is called assumptive billing or coding, and the OIG specifically states you can't assumptive bill.

Bottom line: Without the notes, the biller should not be adding codes. If she is unsure, she should send the charge ticket back to your office, asking whether the physician performed any other procedures for which she should bill.