With today’s financial situation, it is even more important that rheumatology practices know the rules of billing. Billing correctly in the beginning will save you time and money in the long run.
Here are five of the biggest myths about coding and billing:
You must have a different diagnosis in order to bill for an evaluation and management service and a procedure on the same date of service.
This myth has been around so long that even some carriers believe it. The CPT manual clearly states:
“The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.”
To avoid an audit, do not bill too many level-four or -five visits.
The truth is that this is a form of fraudulent coding. It is just as wrong to undercode as to overcode. Also, by doing so, you are hurting your fellow rheumatologists in your surrounding area. This unfairly labels your fellow rheumatologists—who are coding correctly—as outliers.
If Medicare pays for a service and you get reimbursed for it, you must be billing correctly.
Medicare is famous for paying for nonallowed services. They have the right to audit claims as far back as three years. This frequently happens because many simple claims are paid by an automated system, and if that code has not been flagged in their system the first time, it will go unchecked until they audit themselves—and then they audit you.
There is no need to return any money until the carrier requests it.
To Medicare, the difference between fraud and abuse is the intent. If incorrect billing is determined to be abuse, a simple repayment of the funds is requested. If it is determined to be fraud, a practice could face fines up to $10,000 per line item. It is best to audit your own claims to find potential errors and send back overpayment within 60 days of discovery rather than letting the carrier discover the error.
The carrier told me to bill this way so it must be correct.
Insurance companies grade their employees on how quickly they answer your questions, not the accuracy of the information. Always document what you were told, the date, and the complete name of the person you spoke with and always verify what the customer service representative tells you with their written policy.