LStana
Networker
Hello. I have conflicting information. If we know that a surgical assist will not be allowed for a procedure, do we bill it out anyways to get the denial, or do not bill it at all. Thank you for your help!
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Wiki Coding for Surgical Assist (PA or NP)
- Thread starter LStana
- Start date
Pam Warren
True Blue
From Medicare's Fraud and Abuse guide: (see bolded statement below)
Attempts to defraud the Medicare program may take a variety of forms. The following are some examples of how fraud may be perpetrated:
• Billing for services or supplies that were not provided
• Altering claim forms to obtain a higher reimbursement amount
• Deliberately applying for duplicate reimbursement in order to get paid twice
• Completing Certificates of Medical Necessity (CMNs) for patients not personally and professionally known by the provider
• Unbundling or ―exploding‖ charges
• Soliciting, offering, or receiving a kickback, bribe, or rebate
• False representation with respect to the nature of the services rendered or charges for such services, identity of the person receiving or rendering the services, dates of the services, etc.
•Filing claims for services that are non-covered but billed as if they were covered services
• Claims involving collusion between a provider and a beneficiary, resulting in higher cost or charges to the Medicare program
• Use of another person‘s Medicare card in obtaining medical care
• Collusion between a provider and a carrier employee
• Any act that constitutes fraud under applicable federal or state law
So if you know that the service is not covered/billable, such as a surgery that disallows an assistant, you should not bill it out just to get the denial, unless you're absolutely sure your secondary payer will cover it.
Attempts to defraud the Medicare program may take a variety of forms. The following are some examples of how fraud may be perpetrated:
• Billing for services or supplies that were not provided
• Altering claim forms to obtain a higher reimbursement amount
• Deliberately applying for duplicate reimbursement in order to get paid twice
• Completing Certificates of Medical Necessity (CMNs) for patients not personally and professionally known by the provider
• Unbundling or ―exploding‖ charges
• Soliciting, offering, or receiving a kickback, bribe, or rebate
• False representation with respect to the nature of the services rendered or charges for such services, identity of the person receiving or rendering the services, dates of the services, etc.
•Filing claims for services that are non-covered but billed as if they were covered services
• Claims involving collusion between a provider and a beneficiary, resulting in higher cost or charges to the Medicare program
• Use of another person‘s Medicare card in obtaining medical care
• Collusion between a provider and a carrier employee
• Any act that constitutes fraud under applicable federal or state law
So if you know that the service is not covered/billable, such as a surgery that disallows an assistant, you should not bill it out just to get the denial, unless you're absolutely sure your secondary payer will cover it.