Practice Management Alert

Question: Texas Medicaid only will authorize a PET neck to mid thigh (78815) and will not authorize a PET whole body scan (78816). When the patient actually had the PET he was self pay at that time but because of multiple medical bills became eligible for Medicaid and Medicaid will only authorize the 78815. I think some reimbursement would be better than none, but am leery of down coding. Is there something wrong in billing a lesser code even though you actually performed a higher code?

Texas Subscriber

Answer: You should not be downcoding, especially just for reimbursement sake. You should not choose the codes you bill based on the reimbursement you expect to get. You need to report the codes that accurately reflect the work the physician did and the services or procedures the patient had.

If an auditor reviews your records and determines that you're deliberately downcoding claims, they'll conclude that you've been coding improperly. This has been a focus of the Office of Inspector General (OIG) in the past.

If you're deliberately undercoding Medicaid claims to stay under the radar or to get money, you're technically violating the False Claims Act because you are knowingly submitting a false claim. It's a violation just like deliberate upcoding is a violation.