Pain management clinic owes Medicaid $1 million for “upcoding”

[Agast]

CT pain medicine practice to pay $1M in Medicaid settlement

Attorney General William Tong’s office on Thursday announced the settlement with PCA...

www.nhregister.com

“The state alleges PCA coded almost all of its claims “second most complex level of service” regardless of what care service was actually provided.”

Sounds like they billed mostly 99214 as a pain clinic…which begs the question which part of pain management was not considered complex? Hold onto your butts, the audits are coming….

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[myrandom2003]

Why do we still take government insurances? Jail time, audits, paybacks… for what?

Well good thing now that the new coding rules consider medication management, whether that is a discussion to continue medication, change medication, or change dose all count as a 4.

Not trying to start a discussion on coding.

 

[potcake76]

Why do we still take government insurances? Jail time, audits, paybacks… for what?

Well good thing now that the new coding rules consider medication management, whether that is a discussion to continue medication, change medication, or change dose all count as a 4.

Not trying to start a discussion on coding.

Completely disagree that all med mgmt counts as a 4. A refill with no change in dose is a 2. Level 3 at the most, but certainly not a 4.

 

[Taus]

Completely disagree that all med mgmt counts as a 4. A refill with no change in dose is a 2. Level 3 at the most, but certainly not a 4.

Opioid? the work/diligence needed to decide to rx refill, even if stable dose is a level 4

Others, gaba, muscle relaxer etc…mixed 3/4

 

[myrandom2003]

Completely disagree that all med mgmt counts as a 4. A refill with no change in dose is a 2. Level 3 at the most, but certainly not a 4.

You do you boo

I don’t make up the rules, I just bill according to the rules. Also have passed all previous hospital internal audits.

https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

What is considered "prescription drug management" for 99214?

I have an appendix section from AACAP that says when considering risk level within the MDM, that "the risk of complications...includes the possible management options selected and considered, but not selected, after shared medical decision making with the patient and/or family." Does this mean...

forums.studentdoctor.net

 

[bedrock]

Agree with Taus. level 4 is doing Med management. Particularly an opioid, even a refill, due to risk.

And billing anything as a level two is just silly for a specialist. I’ve never billed a 2 in my life.

 

[Orin]

In general, we should be Level 3/4 visits. Level 5 for complex cases involving cancer, multiple comorbidities, surgical events, etc.

From the article: "The investigation by the attorney general’s office “focused on whether starting in 2013, PCA ‘upcoded’ or used codes that would reimburse their office at a higher rate than PCA deserved when submitting claims for services they provided to patients"

They likely changed their practices and started pushing higher codes. That change triggered more evaluation and they likely had poor documentation, opting to settle rather than defend themselves in a lengthy process.

Private practices will continue to get more scrutiny while larger hospital based/academic practices can bill level 4/5 all day.

 

[DrMDAware]

I recently met with a billing specialist and another physician who gets audited and both recommended it is not necessarily the number of level 4 visits vs the national average (that’ll get you audited) but rather the documentation that’ll keep you out of trouble.

 

[MitchLevi]

Completely disagree that all med mgmt counts as a 4. A refill with no change in dose is a 2. Level 3 at the most, but certainly not a 4.

No offense, but this is an absurd post.

If you're Rx'ing an opiate that pt is a 214 whether the problem is stable or worsening, whether the visit took 4 min or 34 min and whether or not you did a complete physical exam or ROS.

Refilling gabapentin is a 213.

Refilling gabapentin and an opiate is a 214.

Every single office visit conducted by a pain physician requires both an imaging review and at least a brief chart review.

I've billed a couple of 215/205, but these are maybe 1-2 per year.

 

[Welcome123]

Completely disagree that all med mgmt counts as a 4. A refill with no change in dose is a 2. Level 3 at the most, but certainly not a 4.

Completely disagree, if you are continuing prescription medication it is a 4 by definition. Arguably, any opioid management can be a 5-it is a medication that requires monitoring and may be considered life threatening by the standards of any malpractice attorney

 

[Welcome123]

Most physicians, especially specialist have a tendency to downcode. Either incorrect understanding of the billing/coding process or lack of care for the small difference in revenue with a belief that the bulk of the earnings are from procedures so why bother with a single level difference on payment.
This undervalues our service across the board and creates a flag for doctors who are outside the “norm”

FYI, You may have heard that you can get in trouble for down coding. I think that is nonsense. No third party audit service will ever tell an insurer you didn’t pay this doctor enough money. Has anyone ever heard of an auditor saying we actually owe you money?

 

[Orin]

FYI, You may have heard that you can get in trouble for down coding. I think that is nonsense. No third party audit service will ever tell an insurer you didn’t pay this doctor enough money. Has anyone ever heard of an auditor saying we actually owe you money?

I completely agree.

The troubles described with downcoding is in the setting of another inducement to the patient. I can't think of a reasonable version of this. I assume it's generally with downcoding procedures such as blocks to trigger points or something so the patient keeps coming back to you? I have yet to see an example of this publicized.

 

[Pain Applicant1]

I'm not sure why people always debate this. Billing is not subjective but objective. I've done my own billing for my own practice for many years now and have studied billing in depth. Just check off the criteria you filled and you'll have your answer on how to bill each claim.

Disclaimer: I've studied billing prior to the recent changes applied to Medicare.

 

[mid|ine]

You need 2 "columns" to hit level 4. Refilling percocet will get you to a level 4 (arguably even level 5) for 1 of 3 columns. Now you need to ADDRESS 2 problems or have a new problem or have a problem with an exacerbation to hit lvl 4.

 

[SSdoc33]

I'm not sure why people always debate this. Billing is not subjective but objective. I've done my own billing for my own practice for many years now and have studied billing in depth. Just check off the criteria you filled and you'll have your answer on how to bill each claim.

Disclaimer: I've studied billing prior to the recent changes applied to Medicare.

disagree.

i find the billing rules to be purposely ambiguous. it depends on how you classify each problem and what counts as a different body part. ill just keep on clicking on level 4s if you do something, level 3 if you dont

 

[SSdoc33]

You kneed 2 "columns" to hit level 4. Refilling percocet will get you to a level 4 (arguably even level 5) for 1 of 3 columns. Now you need to ADDRESS 2 problems or have a new problem or have a problem with an exacerbation to hit lvl 4.

View attachment 352106

what a colossal waste of time this chart is. whoever came up with these rules should be tarred and feathered (?AMA?)

 

[Pain Applicant1]

disagree.

i find the billing rules to be purposely ambiguous. it depends on how you classify each problem and what counts as a different body part. ill just keep on clicking on level 4s if you do something, level 3 if you dont

Midline is right. That's the chart you need to use to bill correctly. There really is no ambiguity as everything is already classified. I'm not saying I'm right but I've really studied this in-depth. I have another chart cheat sheet if anyone cares.

I believed it was developed not by the AMA but by an economist. The guy felt he knew a way to pay doctors fairly. I can link it later if you want. I have to go do a plumbing repair. Hot water smells like rotten eggs.

 

[10KHertz]

Calm down…
The state was going after a corrupt chiropractor owned pain clinic with rotating foreign doctors . Purely a pain mill. Forced injections and chirocare. Massive opioid diversion. This is not a typical pain practice .

 

[MD87]

You need 2 "columns" to hit level 4. Refilling percocet will get you to a level 4 (arguably even level 5) for 1 of 3 columns. Now you need to ADDRESS 2 problems or have a new problem or have a problem with an exacerbation to hit lvl 4.

View attachment 352106

Problem 1: chronic pain of whatever area. Problem 2: Chronic opioid use.
Level 4.

 

[Welcome123]

You need 2 "columns" to hit level 4. Refilling percocet will get you to a level 4 (arguably even level 5) for 1 of 3 columns. Now you need to ADDRESS 2 problems or have a new problem or have a problem with an exacerbation to hit lvl 4.

View attachment 352106

I agree. However it is hard to imagine any chronic pain patient/especially on opioid meds to have only one problem. E.g. lumbar pain/ hip pain, leg pain, gait dysfunction,.. etc.
this is why based on the above chart, I believe almost all prescription pain refill is a 4. I also believe the argument for a 5 on any opioid refill is strong as well. Most doctors will not want to deal with an audit flag like using a 5 for opioids.
Hence the minimizing of our value as a whole.

 

[powermd]

So what about billing based on time?

Is that not allowed anymore?

 

[Orin]

So what about billing based on time?

Is that not allowed anymore?

Still there. Added in incremental add-ons for extended time in 15 minute aliquots with the 99417 code.
Added in any time by a qualified healthcare provider, reviewing charts, coordinating care, etc so it's more than just face to face time.

https://webfiles.gi.org/links/pm/KuoSlides.pdf

 

[Ducttape]

Most physicians, especially specialist have a tendency to downcode. Either incorrect understanding of the billing/coding process or lack of care for the small difference in revenue with a belief that the bulk of the earnings are from procedures so why bother with a single level difference on payment.
This undervalues our service across the board and creates a flag for doctors who are outside the “norm”

FYI, You may have heard that you can get in trouble for down coding. I think that is nonsense. No third party audit service will ever tell an insurer you didn’t pay this doctor enough money. Has anyone ever heard of an auditor saying we actually owe you money?

actually i have heard of a case where level 2 billing was considered downcoding and the practice had to repay. this is word of mouth tho.

key point - the practice had to pay back the level 2s, did not get money out of the situation, for fraudulent billing.

I agree. However it is hard to imagine any chronic pain patient/especially on opioid meds to have only one problem. E.g. lumbar pain/ hip pain, leg pain, gait dysfunction,.. etc.
this is why based on the above chart, I believe almost all prescription pain refill is a 4. I also believe the argument for a 5 on any opioid refill is strong as well. Most doctors will not want to deal with an audit flag like using a 5 for opioids.
Hence the minimizing of our value as a whole.

opioid medications by themselves are by Medicare guidelines not considered the high risk medications.
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/PY2013_High_Risk_Meds.pdf

to summarize 359 pages of meds, the only opioids were codeine combo cough syrups (not codeine alone) and meperidine.

dont forget to comment on reviewing PMP and UDS as part of the assessment to make it closer to level 4, but i would worry that any level 5 routinely would encourage an audit...

So what about billing based on time?

Is that not allowed anymore?

rumor has it that next year all billing will be transitioned to time based billing...

i highly doubt any of us are doing time based billing for level 5.. even level 4 is difficult to attain (25 min for fu)

 

[mid|ine]

I agree. However it is hard to imagine any chronic pain patient/especially on opioid meds to have only one problem. E.g. lumbar pain/ hip pain, leg pain, gait dysfunction,.. etc.
this is why based on the above chart, I believe almost all prescription pain refill is a 4. I also believe the argument for a 5 on any opioid refill is strong as well. Most doctors will not want to deal with an audit flag like using a 5 for opioids.
Hence the minimizing of our value as a whole.

But you can no longer just list problems, you have to do something about them. Im not sure if

Problem 1: Hip pain - percocet
Problem 2: Shoulder pain -percocet

counts... Can you use the same treatment to address multiple problems? There is plenty of subjectivity when you read the chart. There may be hundreds of pages of clarification, but I don't have a billing degree.

On the other hand, ordering an injection is almost always level 4:

1 or more chronic illnesses with exacerbation - hence the need for an injection, and I always try to use the word exacerbation in my documentation
decision regarding minor surgery with identified risks

 

[Agast]

rumor has it that next year all billing will be transitioned to time based billing...

i highly doubt any of us are doing time based billing for level 5.. even level 4 is difficult to attain (25 min for fu)

This is interesting. My husband spends a minimum of 1.5 hours per patient in his highly specialized practice and he won’t bill time-based level 5 because he’s afraid of getting audited and being found at fault or getting penalized by some spiteful insurance plan. He doesn’t see more than 3 people in a day so I don’t see how he could fail. I wonder if they would actually come back and accuse him of downcoding.

 

[mid|ine]

This is interesting. My husband spends a minimum of 1.5 hours per patient in his highly specialized practice and he won’t bill time-based level 5 because he’s afraid of getting audited and being found at fault or getting penalized by some spiteful insurance plan. He doesn’t see more than 3 people in a day so I don’t see how he could fail. I wonder if they would actually come back and accuse him of downcoding.

That is plain foolish. He should bill the level 5 + the extra time codes. There is NO WAY he would lose an audit when they look at his schedule. Of course if he is paid a salary it may not matter to him and there may be too much risk and no reward.

 

[Agast]

That is plain foolish. He should bill the level 5 + the extra time codes. There is NO WAY he would lose an audit when they look at his schedule. Of course if he is paid a salary it may not matter to him and there may be too much risk and no reward.

No, he runs his own practice on a shoestring budget and does 90% of the things himself. He’s an optometrist but his specialty exams bill under medical codes due to the nature of his work. He thinks that makes his position more vulnerable although I disagree. I told him he should at least bill level 5 for the new patients who take up 3 hours of his time. If I had to spend 3 hours with a patient I would shoot myself.

 

[Welcome123]

That is plain foolish. He should bill the level 5 + the extra time codes. There is NO WAY he would lose an audit when they look at his schedule. Of course if he is paid a salary it may not matter to him and there may be too much risk and no reward.

Just getting an audit is a loss-in terms of time/stress/fees. It is not as simple as -here are my notes. The auditor can be malicious and is incentivized to find ways of recovering money.
I have seen auditors claim cloning for an unchanged neurologic exam over the course of several follow ups. I also know of an auditor who denied the existence of templates, as according to her twenty year history as a coder she had never seen it.
This may seem funny but the insurance companies don’t care how absurd the auditor is and they can use this as basis for a clawback

 

[Welcome123]

actually i have heard of a case where level 2 billing was considered downcoding and the practice had to repay. this is word of mouth tho.

key point - the practice had to pay back the level 2s, did not get money out of the situation, for fraudulent billing.



opioid medications by themselves are by Medicare guidelines not considered the high risk medications.
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/PY2013_High_Risk_Meds.pdf

to summarize 359 pages of meds, the only opioids were codeine combo cough syrups (not codeine alone) and meperidine.

dont forget to comment on reviewing PMP and UDS as part of the assessment to make it closer to level 4, but i would worry that any level 5 routinely would encourage an audit...


rumor has it that next year all billing will be transitioned to time based billing...

i highly doubt any of us are doing time based billing for level 5.. even level 4 is difficult to attain (25 min for fu)

I think there is more to that story-

 

[Welcome123]

I think there is more to that story-also for the medication list -It is odd that 25mg po Benadryl is there

 

[mid|ine]

The number of patients is so small, the audit risk would also be small. They would do a preliminary survey and the contents of the notes are irrelevant when billing time based. Its easy to show and prove that the time is as billed/documented in her husbands case. If he is worried about being audited, I would go out of network and opt out of medicare and bill fee for service...

 

[10KHertz]

The reality is that they will always audit the high volume providers and attempt to intimidate your billing practices. If you follow the above advice and documentation, you should be fine. Avoid 99215 in general . Avoid billing post surgeries . The rumor was everything becomes 99213 reimbursement in spite of your care . Kinda like deleting consultative 99244 visits. They don’t care about quality anymore , just more profits at our specialist expense… we are glorified mid levels now

 

[lobelsteve]

No, he runs his own practice on a shoestring budget and does 90% of the things himself. He’s an optometrist but his specialty exams bill under medical codes due to the nature of his work. He thinks that makes his position more vulnerable although I disagree. I told him he should at least bill level 5 for the new patients who take up 3 hours of his time. If I had to spend 3 hours with a patient I would shoot myself.

My sister does the same thing. Busy day might be 6 kids. Notes are never less than 10 pages dictated. Always charting on nights and weekends. Rare diseases with suboptimal treatment. Maybe a nobel prize if she figures it out. Not saying much, but smarter than me by a lot.

 

[clubdeac]

What about independent interpretation of imaging? This qualifies as a level 4. However I’ve had coders tell me I can only interpret an image once. Once I’ve interpreted it at one visit I can’t do it again during another visit even if I’m reviewing the MRI again before considering another injection. Would you all agree? I feel like that’s bull****.

Sometimes I’ll even go back and review my fluoro pics if the patient didn’t end up getting relief. If I dictate that I feel like that should count as an independent interpretation as well by their definition

 

[Ducttape]

What about independent interpretation of imaging? This qualifies as a level 4. However I’ve had coders tell me I can only interpret an image once. Once I’ve interpreted it at one visit I can’t do it again during another visit even if I’m reviewing the MRI again before considering another injection. Would you all agree? I feel like that’s bull****.

Sometimes I’ll even go back and review my fluoro pics if the patient didn’t end up getting relief. If I dictate that I feel like that should count as an independent interpretation as well by their definition

sorry no. youve already seen the image once. looking at it again and again and again and reporting as looking at it the first time and essentially billing for it (as it affects your reimbursement) is kind of an easy way to cheat the system of money.


in my notes, i oftentimes repost the report of images to get insurance company approval, but i do not "count" that as part of my coding for level of care.


can you imagine radiologists doing this? "on review, i see a small sebaceous cyst in 1 cut no where near spine. submitted for second bill".

 

[Pain Applicant1]

If you want to learn billing it would probably help to understand this sheet back and forth. This is what the auditors used to use to audit. I'm not sure what they're doing now but it's probably not much different. This is why, IMO, there is very little ambiguity left on the table for anyone who has a solid understanding of the billing process. From what I see posted throughout these threads, I don't think most doctors are that familiar with how billing works.

I've been doing my own billing for about 10 years now. I have Athena helping me with some of it but I used to do the entire thing on my own. FWIW, I consider myself to be better than most of the commercial billers out there. I've compared myself to the other billers I've used in the past.

 

[Ducttape]

this is really old and i used it in the past.

audits are not quite a stringent as the total numbers that this document requires.

what is not included is that auditors compare your actions to those of your peers, and if you are billing outside of what your peers are billing, then there may be cause for concern.

 

[drrosenrosen]

sorry no. youve already seen the image once. looking at it again and again and again and reporting as looking at it the first time and essentially billing for it (as it affects your reimbursement) is kind of an easy way to cheat the system of money.


in my notes, i oftentimes repost the report of images to get insurance company approval, but i do not "count" that as part of my coding for level of care.


can you imagine radiologists doing this? "on review, i see a small sebaceous cyst in 1 cut no where near spine. submitted for second bill".

Except a radiologist's entire bill is for interpretation of imaging. They're not using E&M codes. Whereas we are gathering and interpreting data, even if it's data we've looked at before, to come to medical decisions about patient's care. I agree that I should be able to count review of an MRI/lab/previous records more than once if it goes into my thought process and decision making. I understand, however, that this is not the way the rules are set up, so I don't.

 

[Pain Applicant1]

this is really old and i used it in the past.

audits are not quite a stringent as the total numbers that this document requires.

what is not included is that auditors compare your actions to those of your peers, and if you are billing outside of what your peers are billing, then there may be cause for concern.

Old but was still relevant up until the most recent CMS changes about a year ago. Was it about a year ago? I think so.

 

[Welcome123]

sorry no. youve already seen the image once. looking at it again and again and again and reporting as looking at it the first time and essentially billing for it (as it affects your reimbursement) is kind of an easy way to cheat the system of money.


in my notes, i oftentimes repost the report of images to get insurance company approval, but i do not "count" that as part of my coding for level of care.


can you imagine radiologists doing this? "on review, i see a small sebaceous cyst in 1 cut no where near spine. submitted for second bill".

With new time based em coding -the time used for review -regardless of previous reviews on previous encounters-will still count for the em code. It is unlikely that you will remember all imaging details/reports and if you are putting in time to review, regardless of number of encounters, this should be compensated and included.
To be fair the radiology reference is not relevant since they are not reviewing randomly for medical decision making

 

[Ducttape]

i disagree. if we cannot be comfortable with an initial interpretation, if we reinterpret multiple times, then that questions our ability to interpret in the first place.



also, that is a fertile grounds for abuse if one can just repeat an image report and "reinterpret".

there could be a plain xray done 9 years ago and on MRI done 8 years ago and some doc would count that for review, when the patient has been seen 35 times since then. abuse of the system is why we dont get to keep shiny toys

 

[RoloTomassi]

Orthopedic surgeon allegedly exaggerated patient visits to defraud insurers

An orthopedic surgeon from Canton, Mass., faces 11 counts of healthcare fraud after allegedly

www.beckersspine.com

Interesting. Seems like he was doing level 3/4s as a specialist and writing opioids. They are alleging time-based billing fraud since he was high volume (60-90/day) without discussion of complexity.

Facing up to 10 y per charge!

 

[Agast]

Orthopedic surgeon allegedly exaggerated patient visits to defraud insurers

An orthopedic surgeon from Canton, Mass., faces 11 counts of healthcare fraud after allegedly

www.beckersspine.com

Interesting. Seems like he was doing level 3/4s as a specialist and writing opioids. They are alleging time-based billing fraud since he was high volume (60-90/day) without discussion of complexity.

Facing up to 10 y per charge!

Sounds like he wasn’t operating much but running a pill mill instead. What a waste of an orthopedic residency!

 

[mid|ine]

The charges don't state that he was using time based billing, which would be stupid for someone seeing 60+ patients per day.

 

[MitchLevi]

Orthopedic surgeon allegedly exaggerated patient visits to defraud insurers

An orthopedic surgeon from Canton, Mass., faces 11 counts of healthcare fraud after allegedly

www.beckersspine.com

Interesting. Seems like he was doing level 3/4s as a specialist and writing opioids. They are alleging time-based billing fraud since he was high volume (60-90/day) without discussion of complexity.

Facing up to 10 y per charge!

This sounds like BS.

60 to 90 per day IS most likely BS medical care, but if he's writing Rx I don't see the problem here...What am I missing?

 

[clubdeac]

sorry no. youve already seen the image once. looking at it again and again and again and reporting as looking at it the first time and essentially billing for it (as it affects your reimbursement) is kind of an easy way to cheat the system of money.


in my notes, i oftentimes repost the report of images to get insurance company approval, but i do not "count" that as part of my coding for level of care.


can you imagine radiologists doing this? "on review, i see a small sebaceous cyst in 1 cut no where near spine. submitted for second bill".

So I assume you also would not count any review of old data in your MDM which I think is terribly inaccurate and erroneous.

Say you see a patient whom you previously saw 6 months ago for radicular pain relieved with an epidural. Comes back with axial lbp. You review the old MRI and xrays again as well as any labs. That’s 3 tests and technically counts as a level 4 in review of data.

You’re saying that no matter what, the fact that you reviewed the data at some point in the past negates you from counting this towards your MDM? I typically need to refamiliarize myself with imaging before reinjecting if it’s been over 3 months. That’s just good medical care.

Nowhere in the new billing/coding guidelines does it say you can’t do this as far as I’m aware. You’re just assuming it means that. If it does I certainly would like to know

 

[RoloTomassi]

That data category of MDM is hardest to hit but easy to bypass by doing the other two categories, since you don't need all three.

Problems: 2 stable problems (lumbar spondylosis, lumbar disc degeneration)

Risk: either prescription medication or elective injection with risk discussion.

Done. Level 4.

 

[clubdeac]

That data category of MDM is hardest to hit but easy to bypass by doing the other two categories, since you don't need all three.

Problems: 2 stable problems (lumbar spondylosis, lumbar disc degeneration)

Risk: either prescription medication or elective injection with risk discussion.

Done. Level 4.

So every epidural with a risk discussion reaches level 4? I think duct will disagree with you on this as well. In other posts he has said it’s only a level 3 unless patient identifiable risk factors.

Also you’re counting lumbar DDD and spondylosis as two separate problems? You think that’s better than coding for a reread of an MRI you haven’t read in a year?!

 

[Ferrismonk]

So every epidural reaches level 4 with a risk discussion? I think duct will disagree with you on this as well. In other posts he has said it’s only a level 3 unless patient identifiable risk factors.

You better hope he never audits your charts

With two problems, independently evaluated, and a moderately dangerous treatment plan with a discussion of risks, yes it's a 4.

 

[RoloTomassi]

This sounds like BS.

60 to 90 per day IS most likely BS medical care, but if he's writing Rx I don't see the problem here...What am I missing?

Def BS care, possibly pill mill, which drew attention and scrutiny. Probably trying to get him on whatever they can, like Al Capone for tax evasion. Lesson though is some better documentation can go a long way.