Wiki fraudulent coding

[tgenia]

Hi,
I am needing some info to give to my superior's on the description of fraudulent coding.
scenario: I coded out a claim for an laparoscopic unlisted procedure, the insurance changed the code on the EOB and wanted us to accept payment for a open similar procedure (which we did not). My superior said why can't we I said it is fraud and she says where is there info supporting this. Can someone direct me to info supporting my ethics so that I can show them concrete info? Besides I say so!!
Thanks

 

[mitchellde]

Hi,
I am needing some info to give to my superior's on the description of fraudulent coding.
scenario: I coded out a claim for an laparoscopic unlisted procedure, the insurance changed the code on the EOB and wanted us to accept payment for a open similar procedure (which we did not). My superior said why can't we I said it is fraud and she says where is there info supporting this. Can someone direct me to info supporting my ethics so that I can show them concrete info? Besides I say so!!
Thanks

Am not certain you are correct that this is fraud, normally when you use an unlisted code you make a not in field 19 with the compare to code and you set you fee to be somewhat close to that procedure. Without any further information, this may be exactly what the payer did. I am curious as to why you think it is fraud.

 

[Pam Warren]

Unlisted procedures are subject to payer discretion. What did you expect to receive for payment on an unlisted code? There would be no fee schedule, and there are no guidelines in CPT with regards to an unlisted code, which is why you enter in Box 19 as Debra mentioned your understanding of the most appropriate best guess. They paid you based on what they felt was the appropriate code because you didn't indicate a comparitive code. They didn't commit fraud; but you also didn't submit a clean claim.