Urology Coding Alert

The basics: The name and identification number (NPI/PIN) you enter on the CMS-1500 form must be the name and number of the provider who actually rendered the service to the patient. The only exception to this rule is incident-to billing.

Warning: Don't report one physician incident-to another physician, because incident-to applies only to nonphysician practitioners.

Clearly stated: On the back of the CMS-1500 form, there is a statement indicating that physicians are specifically certifying that they performed the services for which you are billing or that the services represented incident-to services.

Caution: "Although most physician practices submit claims electronically, they really should not forget that the certification language on the paper CMS-1500 form still applies," says Jean Acevedo, LHRM, CPC, CHC, senior consultant with Acevedo Consulting Inc. in Delray Beach, Fla.

The penalty: Reporting services not performed by the provider indicated on the CMS-1500 is a direct violation of compliant practice operations. If you or your urologists falsify a claim by billing services under another physician's name and ID numbers, you could both face fines or even imprisonment.

Looking once again at the back of the CMS-1500 claim form, you will see the following wording: "Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties."

Third-party billing companies can also end up in hot water for knowingly billing services for a physician under another physician's name, says Katherine Abel, CPC, billing administrator with Stat Solutions in Nashville, Tenn., and senior instructor for e-learning for the American Academy of Professional Coders.

What to do: The OIG Compliance Program Model Guidance for Third-Party Medical Billing Companies offers guidance on what you should do if you're asked to bill fraudulently in this manner, Abel says. The OIG's model guidance states: "If the billing company finds evidence of misconduct on the part of the provider that they service, the billing company should refrain from the submission of questionable claims and notify the provider in writing within 30 days of such determination."

Best bet: First, "gently remind" the urologist that you cannot submit the claim under another physician's name and ID because it does not meet the criteria for incident-to billing, Acevedo says. If the urologist insists on billing in this manner, turn to your supervisor, office manager or compliance officer for assistance in resolving the issue.

Final say: "Under no circumstances, however, does a biller or coder want to be complicit in submitting a 'false claim,' " Acevedo says. Don't submit the claim unless the physician allows you to do so under the proper identification number. If the provider insists on billing with misleading information, terminate your work with him, as painful as that may be.