Pathology/Lab Coding Alert

Some coding practices could trap you.

If you’re holier-than-thou about healthcare providers who are accused of Medicare fraud or abuse, you need to scrutinize some of your own habits. 

Certain systems or routines that you use as you file Medicare claims could put you at risk. Read on to master the difference between fraud and abuse, and to get a refresher on claims-filing behaviors you need to avoid.

See What Constitutes Fraud

Although you may think of fraud and abuse as the same thing, they are different. “Fraud occurs when someone intentionally falsifies information in an effort to deceive Medicare,” explains Gail O’Leary, consultant with Part B Medicare Administrative Contractor (MAC) NGS Medicare in a recent webinar, “Medicare Fraud and Abuse.”

When a provider bills for a service he never performed or certifies that care is medically necessary — when it’s not — that’s fraud.

The Fed looks at several types of fraud that go beyond lying about medical necessity or billing for care that was never rendered. Those include the following examples from the NGS materials:

• Revise documentation to receive a higher payout.
• Send duplicate bills on purpose.
• Facilitate a kickback scheme.
• “Misrepresent” administered services.
• Bill noncovered services as covered services.
• Put Medicare as the secondary payer when there is no primary.
• Usurp other patients’ Medicare Beneficiary Identifiers and engage in identity theft.
• Violate the Conditions of Participation knowingly.
• Set up a scheme between the provider and beneficiary to split Medicare payments.

Don’t Get Duped by ‘Abuse’ Errors

Abuse deals more heavily with the coding and billing side of Medicare, so lab coders should beware of unintentional practices that could land them in trouble.

Whether intended or not, abuse involves getting around the claims rules and receiving improper payment for Medicare services.

Top abuse scenarios, according to NGS, include:

• Unbundling codes and receiving higher payments on Medicare claims.
• Upcoding to higher-level codes that include higher Medicare payments.
• Incorrectly coding claims that aren’t supported by the documentation.
• Sending claims to Medicare first instead of the primary payer.
• Excessively charging patients for services and supplies.
• Ignoring rules about deductible waivers, advance beneficiary notices (ABNs), and more.
• Violating “Medicare participation agreements” that relate to supplier standards.

Example: Unbundling is a real problem for CMS and is something the MACs are on the lookout for, O’Leary suggests. Unbundling “occurs when a provider submits separate bills for lab services that combine three to four tests, which are intended to be billed as one service,” she says.

As a result of those separated bills, “Medicare pays more for each service than if that service were billed as a group [as it was meant to be]. That is unbundling,” O’Leary adds.

Resource: Review more CMS guidance on fraud and abuse at  Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf.