by Jackie Stack, AAB, CPC, CPC-I, CFPC, CEMC, CPEDC, CCP-P

Failure to properly document that dual chamber pacemaker implant can arrest reimbursement if medical necessity isn’t proven. Indications differ for the implantation of single and dual chambered pacemakers, and Highmark Medicare Services suggest documentation you will want to include when submitting a pacemaker implant claim:

1.  Complete History and Physical: An in-depth history and physical is important. Historical information regarding the patient’s medical care, alternative treatments and pertinent lifestyle changes should be included. If single-chamber pacemaker has been previously attempted, note this.
2. List of Medications: Current medications for this hospital stay, along with information on previous medications that the provider has tried. Include whether the medication was effective, the type of symptoms the patient had, and any adjustments made in medications.
3. Diagnostic Reports: Include any diagnostic report that may have been performed. The diagnostic tests to support the surgical procedure may have happened on the billed “Date of Service” or prior to it. Include the patient’s prior inpatient/outpatient services that include any diagnostic tests performed supporting why a dual chamber was necessary.
4. Surgical Report: This will provide an accurate description of the procedure and may include mitigating factors affecting the surgery.
5. Pertinent Hospital Documentation: Include all pertinent hospital documentation for the requested dates of service such as physician orders, progress notes from all disciplines, surgical reports, anesthesia evaluations and notes, recovery room records, laboratory reports, etc.

By all means, don’t bill for a dual chamber pacemaker when a single chamber pacemaker was implanted. There are specific criteria listed for dual chamber pacemaker implants in the CMS NCD (Pub. 100-03, Chapter1, Part 1, Section 20.8, Cardiac Pacemakers) indicating medical necessity. These include the following:

1. Patients in whom single-chamber (ventricular pacing) at the time of pacemaker insertion elicits a definite drop in blood pressure, retrograde conduction, or discomfort.
2. Patients in whom the pacemaker syndrome (atrial ventricular asynchrony), with significant symptoms, has already been experienced with a pacemaker that is being replaced.
3. Patients for whom even a relatively small increase in cardiac efficiency will importantly improve the quality of life, e.g., patients with congestive heart failure despite adequate other medical measures.
4. Patients in whom the pacemaker syndrome can be anticipated, e.g., in young and active people, etc.

And remember, the CMS allows the contractor to follow these guidelines when a procedure isn’t medically necessary:

• “If the admission was for the sole purpose of the performance of the non-covered procedure, and the beneficiary never developed the need for a covered level of service, deny the admission;
• If the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e. remove from the DRG calculation), but approve the admission. “

Physicians may find an in-house billing department more intuitive to their individual business practices. That’s certainly a plus. On the downside, however, is the risk of overtaxing employees with too much responsibility, which in turn may compromise the entire practice.

Judy Capko, a health care consultant, author and speaker, advices physicians to designate a key person to direct the flow of their billing department.

“I like to call this person a ‘coder in residence’,” says Capko in an article she recently wrote for Physicians Practice. “A coder in residence is of chief importance to the success of your practice, so you need to select the right person for the job.”

Should the coder be certified? “I think it’s a good idea,” says Capko, who then refers readers to AAPC for certification.

Read the full article on the Physicians Practice website.

AAPC is releasing its 10^th edition of its Medical Billing and Reimbursement online course. “This course is a great way to enhance your coding education by delving into specifics about the health insurance industry and different reimbursement methodologies for correct claim submissions,” said Shelly Cronin, CPC, CANPC, CGIC, CGSC, AAPC Business and Member Development.

The study program is aimed at providing the most up-to-date information relating to Medicare and third-party billing. This latest edition offers textbook, workbook, and audio lectures to add to your learning experience. More information is available at on the AAPC Medical Billing and Reimbursement Course webpage.

Shelley Safian MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA shares proper methodology for coding Rhinoplasty.

Full Article

The demand for AAPC credentialed coders continues to grow

SALT LAKE CITY—April 2, 2010—The American Academy of Professional Coders (AAPC) announced today its membership reached a record high 90,000. Donna Peters, from Yorba Linda, CA was the 90,000th member and to reward her, the AAPC is giving her a CPC® certification exam free of charge. Already the nation’s largest training and certification association for medical coders, the AAPC’s membership continues to grow with its focus on outpatient credentials and strong member services. Read more »

In this month’s Southern California Physician magazine AAPC member Hidy Borden LPN, CPC, CPC-I discusses how to overturn reimbursement denials or avoid them in the first place. This article is not available online, but can be found on page 10 of the February issue.

It is important to remember that the front office sets the impression for the entire practice. Freda Brinson, CPC, CPC-H, CEMC shares the value of patient interaction as well as the little things like appointment reminders. This article provides a good overview of improving office efficiency and the role that coders play.

 Full Article

Brad Ericson, MPC, CPC, COSC shared his perspective on the need for good medical coders to possess a basic understanding of medical terminology and human anatomy. This fundamental background is key to selecting the correct diagnostic and procedural codes based on a physician’s notes written in medical language.

Full Article

Coders and their providers can bone up on coding, regulation, compliance, and billing while earning continuing education units (CEUs) and continuing medical education (CMEs) at AAPC’s 2010 National Conference in Nashville, Tenn. on June 6–9.  This annual event draws thousands of attendees including doctors, medical coders, and office/practice managers to connect on the business side of health care.  This is the first conference to be approved for 15.75 CME (AMA PRA Category 1™) credits.

Read more »

Budget cuts in education and compliance programs may be penny wise but dollar foolish.

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC

Under the False Claims Act (FCA), a health care facility or entity may be held liable for the conduct of its individual employees, or even the conduct of other entities with which it contracts or associates. This holds true even where the health care facility or group practice entity has no knowledge that its employee or contracted entity engaged in the preparation or submission of false claims.

The FCA allows a private-party plaintiff (a qui tam relator or “whistleblower”) to bring suit on behalf of the United States to recover monies paid to persons or entities who submitted false claims to the government. Actions also may be brought by the government directly.

If found guilty, the offending party can be held liable for a civil penalty from $5,500 to $11,000 for each false claim submitted, as well as three times the amount of actual damage to the federal government. Where the action is initiated by a whistleblower/qui tam relator, the defendant also may be required to pay the relator’s costs and attorney’s fees. The two primary statutes relevant to these actions are 31 U.S.C. §3729, which provides the statutory basis for liability, as well as the penalties for violation; and 31 U.S.C. §3730, which provides the statutory requirements for filing of a private civil (qui tam) action, on behalf of the government, against a person or entity who is alleged to have violated 31 U.S.C. §3729.

Liability Doesn’t Require Intent

An action for making a false or fraudulent claim for Medicare or Medicaid reimbursement may be brought when: 1) a false claim (or statement in support of a claim), 2) was presented or caused to be presented to the United States, 3) with the knowledge that the claim or statement was false, and 4) the false claim caused damage to the government.

Although the FCA requires “knowing” presentment of a claim containing false material, the statute (31 U.S.C. §3729(b)) expressly states, “No proof of specific intent to defraud is required.” The statute broadly defines the terms “knowing” and “knowingly” as including “actual knowledge,” “acts in deliberate ignorance of the truth or falsity” of the information submitted on the claim, or “acts in reckless disregard of the truth or falsity of the information” submitted on the claim form. That is, knowledge is imputed (assumed) where it can be shown that the entity acted with reckless indifference or deliberate ignorance.

For example, a single physician in a multi-physician practice group routinely up-codes claims. If the practice fails to take steps to ensure the validity of the claim data, or assumes a “see no evil” approach to billing, the group could be liable under the FCA for recklessly allowing false claims submissions, or for deliberately ignoring evidence that false claims were submitted. Such allegations against the group are especially likely where the government or qui tam relator is confident that it has a better chance of obtaining payment of penalties and damages from the facility. Even in cases where the group practice is not found to have sufficient knowledge, it likely will incur legal expenses to defend itself or the targeted party.

An implied false certification claim under the FCA is based on the principle that the simple act of submitting a claim for reimbursement implies compliance with all governing rules that are a precondition of payment (Mikes v. Straus, 274 F.3d 687, 699 (2nd Cir. 2001)). Although courts have reiterated consistently that mistakes — and even negligence — are not fraud under the FCA (see Wang v. FMC Corp., 975 F.2d. 1412, 1420 (9th Cir. 1992)), there is often a fine line between what constitutes negligent conduct and what is considered reckless.

The Ninth Circuit Court of Appeals held that providers who bill Medicare have a duty to familiarize themselves with the requirements for payment (U.S. v. Mackby, 262 F.3d 821, 828 (9th Cir. 2001)). As a result, reporting in a manner clearly contradicted by statutory or regulatory payment provisions could lead to FCA liability. Where the violation pertains to a provision found in the Centers for Medicare & Medicaid Services’ (CMS) interpretive guidance, liability becomes less certain, and often turns upon whether the applicable provisions are found as a condition of payment or a condition of participation (see Mikes at 699-702).

For example, a qui tam FCA claim was brought against a physician’s group, Heart Doctors, based on the allegedly fraudulent billing of one of the Heart Doctors’ employed physicians. The facts of that case were revealed in subsequent litigation between the physician group, Heart Doctors, and the employed physician, Dr. Lane (Heart Doctors v. Lane, 2006 WL 2692694 (E.D.Ky. Sept. 13, 2006)). Dr. Lane allegedly was instructing nurses to provide chemotherapy procedures without the supervision of a physician, and then directing to bill Medicare as if the procedure had been performed in the presence of the physician. Heart Doctor’s apparently had no actual knowledge that this conduct had occurred; however, the qui tam relator brought the FCA case against Heart Doctors alleging that it recklessly permitted false claims to be submitted. Heart Doctors settled the FCA case for $434,180, and incurred over $100,000 in attorney fees.

Not only do hospitals and health care provider groups face substantial FCA liability as a result of the conduct of those that it employs, or with whom it contracts/associates, but a number of federal courts have held that there is no right to indemnification or contribution for FCA liability from either a co-defendant or from a third party where the indemnification claim is dependent on finding FCA liability by the party seeking indemnification. In other words, even if a single individual within the group is responsible for false claims, the group cannot recover the cost of defending itself and/or penalties from that individual.

As an example, Heart Doctors attempted to obtain indemnification from Dr. Lane because it was Dr. Lane’s conduct that led to Heart Doctors’ FCA liability. Citing a line of cases, the court in Heart Doctors found that a qui tam defendant cannot seek to offset their liability under the FCA through suits seeking indemnification or contribution from a third party. (See Mortgages Inc. v. U.S. District Court of the District of Nevada, 934 F.2d 209 (9th Cir. 1991); U.S. ex. Rel Madden v. General Dynamics Corp., 4 F.3d 827 (9th Cir. 1993)).

Prepare for the Perfect Storm of FCA Liability

Current and possible future conditions favor increased FCA liability for all health care providers.

As the economy worsens, physician payments are diminished, and patients — due to escalating co-payments and deductibles — avoid seeking physician services. These occurrences generally create a motive for physicians/groups to code services more aggressively.

Proposals in Congress may change provisions of the FCA to favor the qui tam relator and the government. See FCA Correction Act of 2007, S.2041 and Substitution S.2041, 110th Cong. (2007); FCA Correction Act of 2007, H.R. 4854, 110th Cong. (2007). These proposals include changes to the way that FCA damages are calculated, the addition of separate liability for the government’s costs of pursuing an FCA case, and elimination of the public disclosure original source rule that bars an FCA qui tam action where the qui tam plaintiff is not the original source of the information that leads to the filing of an FCA case. If these changes are enacted, it is anticipated that many more qui tam cases will be filed.

The Recovery Audit Contractor (RAC) program incents private contractors to find overpayments.

When combined, increased post-payment scrutiny, diminished barriers to filing an FCA case and potentially increased damages, and an incentive for more aggressive coding practices make a near perfect setting for substantially heightened FCA liability for any physician group, hospital, or other entity.

Take Steps to Limit Liability

Hospitals and physician groups make much better targets for qui tam relators (because they tend to have more money). As such, these entities must take deliberate steps to reduce FCA exposure due to the improper employee or contractor conduct. Specifically, employee and sub-contractor education in proper coding and documentation, as well as the relevant rules establishing conditions of payment, is critical. An effective internal audit program will not only identify errors before they get out of hand, but will demonstrate the entity’s efforts at compliance, thereby mitigating the potential that recklessness or deliberate ignorance can be shown.

The bottom line is this: Physician groups can be held liable directly for their own failure to prevent submission of false claims, as well as indirectly where the costs of defending such an action fall to the entity. Moreover, because indemnification is not permitted, hospitals and physician groups should consider stepping up efforts at minimizing FCA liability to preclude the possibility of such an action ever occurring. This may include reconsidering any budget reductions in the area of staff (physicians/coders) education and training, internal auditing, and compliance programs. Given the substantial amounts that can be recovered under the FCA, budget cuts in these areas may end up being “penny wise and dollar foolish.”