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

[smarterchild]

I wonder how this works with midlevel providers? I used to be in a practice where the mid levels would do all the med refill visits under the supervision of a doctor. Each of the 2 mid levels would see 30 patients a day but the visits were billed under the physician, since the doc was in the office and reviewed the patient note. In this case, 60 patients would be billed under one physician but technically he/she would have 2 mid levels seeing them. Would that raise red flags?

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[Welcome123]

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

Abuse of the system? If you look at the 2021 guidelines, any time reviewing counts, look at the emg/mri report or images or even your last visit notes.
I am unclear if we are on the same topic. Are you referring to resubmitting a previous image report for a second read? Or are you referring to using it for your encounter code? There is a clear answer to the second question

 

[Welcome123]

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

The way the mdm formula is set up 2 stable problems managed with prescription med for either or both should be a 4. To your question about “can you use the same treatment to address multiple problems?” yes. Although it does not matter for em coding purposes. Using coder keywords like exacerbation is smart as they may be confused with words they are not trained to understand like aggravating, deteriorating,..
I don’t believe that any issue of double dipping applies
An example of double dipping would be (I do not agree with it but that is the deal we have) doing an ultrasound scan and then using ultrasound guidance -NCCI edits don’t allow you to be paid for the guidance code.
The injection is an injection of prescription medication.
Higher level pain procedures/treatment could be a 5. The discogram is a specific example medicare uses as a 5

 

[Ducttape]

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?!

first, epidurals by themselves are probably classified low risk procedures. we are doing 9,000,000 a year. my take is that the discussion on ESI is level 3, but you can make it moderate risk/ level 4 by discussing risks such as stopping anticoagulation, coordinating care with medical transportation, allergy pre-treatment, other medical or social constraints.

second, reviewing MRIs is part of what we do to make sure the injection is appropriate and safe. reviewing an MRI again and again and saying it is a new interpretation is really not, well, new.

do you think it would be appropriate for an internist to review the sodium level from 8 years ago done in, say, a different hospital at a different state for a completely different condition?

last i checked, lumbar DDD and spondylosis have different ICD-10 codes, so technically they are different per CMS

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

i will try to find the link that was given to me by the auditors who reviewed my charts last year.

 

[BobBarker]

He’s back!

 

[RoloTomassi]

first, epidurals by themselves are probably classified low risk procedures. we are doing 9,000,000 a year. my take is that the discussion on ESI is level 3, but you can make it moderate risk/ level 4 by discussing risks such as stopping anticoagulation, coordinating care with medical transportation, allergy pre-treatment, other medical or social constraints.

Low risk is freezing a wart. Give yourself some credit

 

[clubdeac]

first, epidurals by themselves are probably classified low risk procedures. we are doing 9,000,000 a year. my take is that the discussion on ESI is level 3, but you can make it moderate risk/ level 4 by discussing risks such as stopping anticoagulation, coordinating care with medical transportation, allergy pre-treatment, other medical or social constraints.

second, reviewing MRIs is part of what we do to make sure the injection is appropriate and safe. reviewing an MRI again and again and saying it is a new interpretation is really not, well, new.

do you think it would be appropriate for an internist to review the sodium level from 8 years ago done in, say, a different hospital at a different state for a completely different condition?

last i checked, lumbar DDD and spondylosis have different ICD-10 codes, so technically they are different per CMS


i will try to find the link that was given to me by the auditors who reviewed my charts last year.

Duct you never cease to amaze me…with your subjective inconsistencies. I think there’s some gray area in these coding guidelines and we’ll have to agree to disagree

 

[Ducttape]

He’s back!

i dont post on the weekends.

have a lot of other more enjoyable things to do.

exercise, hang out with kids, watch tik tok, pull hangnails, clean toilets, pick up dog poop, excise hemorrhoids...

 

[mid|ine]

Level 4 is
Minor surgery with identified patient or procedural risks

I think an ESI more than qualifies

 

[bedrock]

Level 4 is
Minor surgery with identified patient or procedural risks

I think an ESI more than qualifies

exactly. It is disgraceful to think that an epidural steroid injection, which could paralyze someone, is not a level 4.

Reminds me of that other poster here recently who said that a medication f/u should be a level 2.

We should have some respect for ourselves and our 13 years of education.

 

[MitchLevi]

LOL at comparing an old sodium lab to an MRI review. How can anyone reply to that?

 

[BobBarker]

i dont post on the weekends.

have a lot of other more enjoyable things to do.

exercise, hang out with kids, watch tik tok, pull hangnails, clean toilets, pick up dog poop, excise hemorrhoids...

Discogram4u

 

[mid|ine]

LOL at comparing an old sodium lab to an MRI review. How can anyone reply to that?

Yeah, if the idea is to capture the level of complexity of the decision making, then it should allow you to go back and re-review old data.

Did an ESI at L5-S1, patient didn't improve. Re-reviewed MRI, decided to change level...

 

[Welcome123]

first, epidurals by themselves are probably classified low risk procedures. we are doing 9,000,000 a year. my take is that the discussion on ESI is level 3, but you can make it moderate risk/ level 4 by discussing risks such as stopping anticoagulation, coordinating care with medical transportation, allergy pre-treatment, other medical or social constraints.

second, reviewing MRIs is part of what we do to make sure the injection is appropriate and safe. reviewing an MRI again and again and saying it is a new interpretation is really not, well, new.

do you think it would be appropriate for an internist to review the sodium level from 8 years ago done in, say, a different hospital at a different state for a completely different condition?

last i checked, lumbar DDD and spondylosis have different ICD-10 codes, so technically they are different per CMS


i will try to find the link that was given to me by the auditors who reviewed my charts last year.

If you are using prescription medication in your epidural and there are two stable problems or one with exacerbation. Example- the patient felt good relief following first epidural then pain gradually worsened to incomplete return of pre injection pain level. It is a 4.
Part of what we do or all of what we do should be reimbursed. We shouldn’t take our work for granted. Comparing this to an internist looking at a dated sodium lab is not comparable
Downcoding minimizes all of us even if it is unintentional.

 

[Ducttape]

Level 4 is
Minor surgery with identified patient or procedural risks

I think an ESI more than qualifies

low complexity is minor surgery with no identified risk factors. not sure how epidurals are classified as having significant procedural risks, especially since CRNAs are allowed to do them.

thats level 3.

Part of what we do or all of what we do should be reimbursed. We shouldn’t take our work for granted. Comparing this to an internist looking at a dated sodium lab is not comparable
Downcoding minimizes all of us even if it is unintentional.

you are conflating analogies. sodium was about reviewing previous tests and counting them as new tests for purposes of level of complexity

 

[mid|ine]

Bleeding, infection, numbness, weakness, allergic reactions to medications, worsening of the pain, long term nerve damage, paralysis.......

I don't know what you have on your consent, but that is only a partial list of procedural risks.

 

[callmeanesthesia]

Bleeding, infection, numbness, weakness, allergic reactions to medications, worsening of the pain, long term nerve damage, paralysis.......

I don't know what you have on your consent, but that is only a partial list of procedural risks.

So does “identified risk factors” refer to risks of the procedure, or patient risk factors such as anticoagulants, diabetes, etc?

 

[Ferrismonk]

So does “identified risk factors” refer to risks of the procedure, or patient risk factors such as anticoagulants, diabetes, etc?

both.

 

[Ferrismonk]

low complexity is minor surgery with no identified risk factors. not sure how epidurals are classified as having significant procedural risks, especially since CRNAs are allowed to do them.

thats level 3.

you are conflating analogies. sodium was about reviewing previous tests and counting them as new tests for purposes of level of complexity

There are CRNAs doing cervical stims. Does that make it a low risk procedure?

Low risk is the aforementioned hangnail removal, moderate risk is the hemorrhoid removal.

Hell, even the ASRA anticoagulation guidelines call ESI an intermediate risk procedure.

 

[Ducttape]

having done hemorrhoid removal, that should be a high risk procedure, but it is not.

a procedure that can be done in an office without any special or CV monitoring, with just local anesthetic, no sedation, in 5 minutes and the patient walks home without even a bandage is a moderate complexity procedure?

really?

we need to be honest with ourselves.



after all, we are quoting these articles as having no complications when they are done on anticoagulants.

(fyi, if insurance allows a CRNA to do a cervical stim, that severely downgrades their assessment of the complexity of spinal injections, doesnt it?)

 

[Welcome123]

low complexity is minor surgery with no identified risk factors. not sure how epidurals are classified as having significant procedural risks, especially since CRNAs are allowed to do them.

thats level 3.

you are conflating analogies. sodium was about reviewing previous tests and counting them as new tests for purposes of level of complexity

If you take time to review past tests regardless of how many times, it counts as you are doing the work and it is your time. I am not clear if I am communicating that.
If you don’t review it then it should not count.
As far as epidural risk. It is the fact that you are using prescription medication that elevates it to a 4, without regards to how you consider it a low risk surgical procedure.
Using the CRNA performing epidurals example is debatable and a tangent that should be another thread.

 

[Agast]

having done hemorrhoid removal, that should be a high risk procedure, but it is not.

a procedure that can be done in an office without any special or CV monitoring, with just local anesthetic, no sedation, in 5 minutes and the patient walks home without even a bandage is a moderate complexity procedure?

really?

we need to be honest with ourselves.



after all, we are quoting these articles as having no complications when they are done on anticoagulants.

(fyi, if insurance allows a CRNA to do a cervical stim, that severely downgrades their assessment of the complexity of spinal injections, doesnt it?)

My malpractice rates are similar to my ortho partners due to the neuraxial component. The liability would imply that what I am doing has some complexity to it.

 

[RoloTomassi]

a procedure that can be done in an office without any special or CV monitoring, with just local anesthetic, no sedation, in 5 minutes and the patient walks home without even a bandage is a moderate complexity procedure?

It's that "easy" because all the training, skill, knowledge of nuances, attention to detail. Smooth case doesn't take away from complexity.

 

[clubdeac]

The fact that insurers, policy makers and admin want to cheapen medicine and the medical care provided by fully trained medical doctors does not mean what we do as doctors is thereby automatically simple sauce. Ducts reasoning is once again illogical

 

[Welcome123]

is this just a clever troll attempt?
It is hard to believe that any physician can be so confident/fixated on down coding

 

[MitchLevi]

having done hemorrhoid removal, that should be a high risk procedure, but it is not.

a procedure that can be done in an office without any special or CV monitoring, with just local anesthetic, no sedation, in 5 minutes and the patient walks home without even a bandage is a moderate complexity procedure?

really?

we need to be honest with ourselves.



after all, we are quoting these articles as having no complications when they are done on anticoagulants.

(fyi, if insurance allows a CRNA to do a cervical stim, that severely downgrades their assessment of the complexity of spinal injections, doesnt it?)

You're wrong.

 

[Ducttape]

Further proof that what motivates some of us on this forum is $$$.


And word of advice: I coded just like you all are doing last september. I was reviewed by an independent firm. I was downcoded by the auditor on 5 out of 10 charts.

 

[Agast]

Doctors are the only professionals who are shamed for expecting fair compensation for their work.

 

[Welcome123]

This is just sad.
I think that you may have had a bad experience and I am sorry that you did not code 50% of your charts correctly. I don’t think that experience can be extrapolated to make you a coding authority. If someone disagrees with you instead of arguing that a nurse can do it, perhaps it may be more constructive to address the issue. If a crna/pa/np/do/md orders a discography study it should be a 5.
When your point isn’t agreed with, then you resort to anyone who disagrees is only concerned with money?

 

[Ducttape]

I did address the issue and the response was as expected - what we are doing is right and what we do is of such high importance and risk.

What we do is easy. The patients are rarely very sick. Risk of serious injury is low. This is not ER medicine where a STEMI can usually code as a level 4.

The auditor was quite instructive.

 

[RoloTomassi]

I did address the issue and the response was as expected - what we are doing is right and what we do is of such high importance and risk.

What we do is easy. The patients are rarely very sick. Risk of serious injury is low. This is not ER medicine where a STEMI can usually code as a level 4.

The auditor was quite instructive.

LOL if a STEMI is a 4, what's it take to get to a 5???

 

[MD87]

LOL if a STEMI is a 4, what's it take to get to a 5???

Acute STEMI + opioid refill.

 

[Agast]

Acute STEMI + opioid refill.

Sorry, the morphine is bundled with the STEMI

You gotta pee test them before they do the 12-lead EKG

 

[lobelsteve]

I did address the issue and the response was as expected - what we are doing is right and what we do is of such high importance and risk.

What we do is easy. The patients are rarely very sick. Risk of serious injury is low. This is not ER medicine where a STEMI can usually code as a level 4.

The auditor was quite instructive.

You got hosed or your charting is subpar. Audit the auditor.

 

[calvnandhobbs68]

I did address the issue and the response was as expected - what we are doing is right and what we do is of such high importance and risk.

What we do is easy. The patients are rarely very sick. Risk of serious injury is low. This is not ER medicine where a STEMI can usually code as a level 4.

The auditor was quite instructive.

I have no idea in what world a STEMI would be a level 4 under the 2021 guidelines.

1 acute or chronic illness or injury that poses a threat to life or bodily function + high risk of morbidity from additional diagnostic testing or treatment (decision regarding hospitalization) = Level 5

It seems there's some bad misunderstanding of the 2021 guidelines here and a conflation with the pre-2021 guidelines which required a certain amount of information per section to hit complexity rather than relying on medical decision making as the controlling factor.

It's a pretty large change for people who were familiar with the pre-2021 guidelines and was basically trying to get away from dermatologists billing 6 99203s an hour for looking at benign moles by hitting all the ROS/vitals checkboxes. Remember that the lawsuit at the beginning of this thread was for cases going back to 2013, so pre-2021 guidelines where they were probably doing subpar "checkbox" documentation for all the 99214s they were billing.

 

[oreosandsake]

all of this bickering amongst ourselves.

the outliers that make the news are the guys doing lines and deciding which exotic to drive today. not most of the SDNerds.

how many of you have ever been audited? and what was the outcome?

have you watched that episode of American Greed where the guy is doing TPI at bedside and billing 3 level TFESI etc? they raided his mansion to take him away. and there was that story of the guy laying down SCS leads on patient's backs and saving the photo... or using the same procedure photo for all the patients. or the doc billing by time but it adding up to more than 24 hours in a day.

you're going to need to be on the far end of the curve to even come up on the radar.

 

[10KHertz]

all of this bickering amongst ourselves.

the outliers that make the news are the guys doing lines and deciding which exotic to drive today. not most of the SDNerds.

how many of you have ever been audited? and what was the outcome?

have you watched that episode of American Greed where the guy is doing TPI at bedside and billing 3 level TFESI etc? they raided his mansion to take him away. and there was that story of the guy laying down SCS leads on patient's backs and saving the photo... or using the same procedure photo for all the patients. or the doc billing by time but it adding up to more than 24 hours in a day.

you're going to need to be on the far end of the curve to even come up on the radar.

Every year by 2-3 insurances at least . Record requests for united health care regularly. Going on for 16 years. If you’re Audited it doesn’t mean your doing anything wrong… actually makes your practice stronger.
FYI the major carriers exchange your billing practice and data . So be cautious.

 

[gaspasser127]

I don’t see how there’s anything bad about knowing the rules of the game and playing accordingly. Blatant fraud is one thing (calling TPIs TFESIs, falsifying procedures, etc).

But Medicare intentionally made level 4 clinic visits more attainable in order to incentivize PCPs who make all their money from clinic visits.

Under coding is fraudulent under the law as well

 

[Dr. Ice]

Under coding is only fraud if you are doing it to try to cover up the fraud you are really committing

 

[smarterchild]

For those of you who have been audited, do you use a special service to handle it or do you just send over the records on your own?

I haven’t been audited yet but just want to be prepared.

There are some services online that will handle everything for you but they are quite expensive.

 

[Pain Applicant1]

Every year by 2-3 insurances at least . Record requests for united health care regularly. Going on for 16 years. If you’re Audited it doesn’t mean your doing anything wrong… actually makes your practice stronger.
FYI the major carriers exchange your billing practice and data . So be cautious.

Can you kindly elaborate, please?

How do they audit you? What exactly does it entail and what has been the outcome?

How do you know the payers exchange data and what's the point of doing so?

 

[pastafan]

I have been "audited" a few times. Received letters telling me to send around a dozen patient charts for review. Sent them, never heard back.

 

[oreosandsake]

c

 

[10KHertz]

Can you kindly elaborate, please?

How do they audit you? What exactly does it entail and what has been the outcome?

How do you know the payers exchange data and what's the point of doing so?

Every carrier is a little different.
United wants records to pay bills.
Cigna sends nasty letters stating you’re an overproduced , outlier, deplorable …
Anthem threatens retractions over a 10year period to scare you, that got heated .I Just went off in a rebuttal letter and they backed off. Happened to a friend as well.

A Medicare inspector walked into the office one day and wanted to inspect durable equipment. Lots of brace fraud , etc, empty practice spaces.
Medicare Tries to retract global period visits,which is appropriate.

All carriers try to retract mod 25 visits, they don’t want to understand our field .

Go through all your eras/eobs and help your biller. For anthem specify right and left vs using “bilateral”. More Nonsense

The future:
Medicare will try to retract all our repeat epidurals performed within 3 months. So change your approach/levels. Tell patients to pay cash for additional procedures and blame this administration…

Anthem is the bank for the federal government and provided our HHS Covid grants. Anthem is changing their name , but they will continue to do the governments dirty work . All carriers exchange your billing practices and implement policy and payment reductions at a national level. CMS then stuffs it down ASIPP throat , and your colleagues sell us out . They publish ****ty articles showing that we dont need multiple epidurals, don’t need rfas, etc. look at ASIPP’s article this month , push to retreat back to therapeutic facets mobs over rfas… I predict more rfa policy changes .

Good luck , nobody gets along and our leaders are douchbags… off to St Thomas .

 

[Welcome123]

Under coding is only fraud if you are doing it to try to cover up the fraud you are really committing

The insurers use third party services that are incentivized to recover funds.
It is unlikely any third party auditor will review charts and say, “This doctor downcoded, we actually owe him money”. What they want to say, “ we paid too much, you have to give money back”
The insurance companies are paying them to “independently” review and they are getting a bonus/more work based on the money they get.
They are not independent and they will bias towards the insurance company

 

[clubdeac]

just had an insurance approve a right L3-5 RFA but not the left side. mbb's were done bilaterally. wtf?

 

[myrandom2003]

I get request from coix for records for audits. Since i do not have a contract with them, I send them a bill for records. Sometimes they pay and sometimes they leave me
Alone. Always send a bill if it is not specifically the insurance carrier requesting records.

 

[Drd105]

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

I do everything here you stated (list probs like that for percocet and use ‘exacerbation’). its doesnt say you can’t use the same tx for multiple probs.

 

[Drd105]

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.

just had an insurance approve a right L3-5 RFA but not the left side. mbb's were done bilaterally. wtf?

This happened to me- the insurance lady didn’t specify that we wanted the other side and the insurance thought we wanted to do the same side again 🙄