- B or D—If it was not documented, it was not done is the motto of many coders. For those who follow this motto, the answer would be B. But there is another option for the coder and that is to query the physician about whether the injection was done with ultrasound guidance or not. The physician is allowed to go back and amend the notes. If it was done with ultrasound guidance, this would mean that none of the answers is correct. A nursing visit is not allowed to be billed with the injection code because the work is built into the relative value unit (RVU) of the injection code. Also, there is not enough documentation to support the medical necessity of an evaluation and management code.
- B—This drug does not meet the standard of the higher chemotherapy infusion code. Even through the drug is a biologic, it does not meet the standard of the extra work needed to bill the chemotherapy infusion code.
- A—Just because a practice has a prior authorization for the date of the visit does not mean the service will be covered. Patients often switch insurance carriers. The patient may have changed employers, their employer may have switched its payer, or the patient may have lost insurance coverage. At each and every visit, especially for infusions, a verification of benefits should be done prior to the patient receiving the infusion. The new carrier may not pay for the infusion if a prior authorization was not obtained from them.
- C—A ZPIC audit means fraud is suspected. Any request made by ZPIC, whether in a letter or if a ZPIC agent visits, must be dealt with immediately. If the request is made by mail, make sure you send all of the necessary documentation and any proof of the medical necessity to support the services. You can contact the ACR to see if we have any resources to aid you. If an agent arrives at your practice, you have to stop what you are doing and give them access to the files they are requesting. It is recommended the practice assign someone to shadow the agent, copy everything the ZPIC agent takes and ensure they are taking all records associated with claims (e.g., radiology images, labs results or notes held outside of the charts, etc.). Also, it is highly recommended the practice look into retaining a healthcare attorney.
- D—You can find the Excluded Individuals/Entries (LEIE) on the OIG website under https://exclusions.oig.hhs.gov. If a practice hires or works with any excluded entity, whether the practice is aware of it or not, the practice can be held accountable with penalties or possibly be placed on the LEIE. If you discover a staff member or a business you are working with is excluded, the relationship must be terminated immediately.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.