Wiki submitting claims to primary commercial ins and secondary ins medicaid

[Jstapleton57]

I have a co-worker who insists that when 99395 is submitted to the primary commercial ins and denied, that the 99395 code can be changed to a 99214 to submit to the secondary ins medicaid plan first to receive payment. I thought this was illegal but I would like to find some information to print off regarding guidelines on this.
Any help would be appreciated.

Judy in Mobile

 

[1formissy]

On a coding and audit perspective, you have to bill exactly what is documented. If the provider performed a physical, than that is the service code you will need to bill. I do not recommend changing codes to try and get payment from a payer.
If the commercial payer is denying, I would research why the claim was denied by the primary payer and follow up with them. This falls under the False Claims Act.

 

[Jstapleton57]

Thank you for your imput. I totally agree with you.

 

[jhendrix08]

Agreed...changing the code sounds like insurance fraud to me.