Truth in billing

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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During the course of a Mohs surgery day you excise a patient’s nasal basal cell carcinoma with Mohs surgery and bill for the procedure with appropriate Mohs surgical CPT codes. As the patient has another, less aggressive basal cell carcinoma on his/her neck, and your Mohs technician is on site producing frozen section slides, you decide to check the excision margins. So you excise this second tumor with the Mohs technique, as well. However, in an effort to save the patient money, you charge for a malignant excision and a frozen section (CPT 88331) rather than for Mohs surgery (CPT 17311). Does this constitute acceptable discounting?

The introduction section to the current CPT manual, titled “Instructions for Use of the CPT Codebook,” contains the following instructional statement: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided.” In the above scenario, the documentation in the patient’s record would show that the neck tumor was excised utilizing the Mohs surgical technique. Although one did an excision and a diagnostic frozen section, the most accurate CPT coding for what was done is CPT 17311, Mohs surgery, first excision stage. This is the only appropriate coding choice.

The above scenario leads to a question: why, when doing Mohs surgery, would one bill for anything other than Mohs surgery? Consider also that the second Mohs surgery done on the same day as the first would be subject to the multiple surgical procedure reduction rule, and would typically be reimbursed at 50 percent of the fee schedule rate. An excision with routine frozen section control would also be subject to the multiple procedure reduction. Doing one procedure (Mohs) but billing for another (excision with frozen sections) would, in the event of a chart audit, raise the question of why one avoided billing for the Mohs surgery. Was it because the indications for Mohs surgery were not adequate? Was it done to skirt insurance company coverage parameters, whereby Mohs surgery would not be covered but an excision with frozen section control would be covered? Such questions, and the answers uncovered, may expose one to accusations of impropriety. [pagebreak]

Medicare contractors support the directives of the CPT: one must code and bill to the highest level of specificity for the service provided. Doing otherwise risks the involvement of the Zone Program Integrity Contractor (ZPIC), other auditors, and the Office of Inspector General (OIG). ZPICs are contractors designated by the Centers for Medicare and Medicaid Services (CMS) to audit medical service providers and suppliers to identify fraud, waste, and abuse. Such audits are done through data analysis and mining, medical records review, and focused investigations including unannounced physician office site visits. A Medicare Administrative Contractor (MAC) may also identify statistical billing outliers and refer such cases directly to a ZPIC for investigation. Discovery of impropriety can lead to demands for specific case-by-case refunds, or worse, to a demand for a refund based upon a percentage extrapolated from a provider’s entire Medicare patient population. Keep in mind that the goal of the ZPICs is to save and/or return money to CMS. If consistent billing impropriety is found, a provider may be subjected to persistent prepayment claims review, whereby all claims are reviewed by the MAC or the ZPIC prior to payment. This can substantially delay payments for legitimate services. Particularly egregious cases suspected of fraud are referred for further investigation by the OIG and possible prosecution by the Department of Justice.

Correct coding applies to all aspects of coding, including the levels of evaluation and management (E/M) provided, procedure as well as associated diagnosis codes, and to treatments of benign as well as malignant lesions. It is inappropriate to manipulate the patient record to suit a patient’s personal desires for insurance coverage when none should be forthcoming. Such a scenario may be: billing for a lesion removal, such as a mole, under the guise of suspected atypia (neoplasm of uncertain behavior), when in reality the lesion or mole is clinically clearly benign and is being removed solely for cosmetic purposes. [pagebreak]

It should be clear that repeated inaccurate or inappropriate selection of CPT coding, whether well-intentioned or not, could lead to dire consequences. Precision and honesty in coding selection will help to keep you clear of investigative grief.

Example 1: As you feel that a morpheaform basal cell carcinoma on a patient’s neck is most effectively treated with Mohs surgery, you excise the lesion with two stages of Mohs surgery, producing a 2.2 cm maximum diameter defect. You also know that the patient’s insurance refuses to pay for Mohs surgery done for lesions located on the neck. So, you bill CPT 11623 for the malignant excision, excised diameter over 2.1 to 3.0 cm, and CPT 88331 for the first stage frozen section and CPT 88332 for the second stage frozen section.

Answer: Incorrect. Although it is tempting to conform billing coding to insurance payment patterns, the fact stays in the medical record that Mohs surgery was performed. Although one may argue that an excision with frozen section margin control was technically done, it was done with the Mohs surgical technique, and that should be accurately reflected in the billing. If one anticipates that an insurer will not recognize a procedure as a covered service, it is best to discuss that situation with the patient prior to the surgery date, so that the patient may be prepared for the financial consequences.

Example 2: A Medicare patient with numerous asymptomatic seborrheic keratoses would like to have some of them removed, as they seem unsightly to the patient. As you know that the destruction of asymptomatic and uncomplicated seborrheic keratoses is not a Medicare covered service, you explore with the patient whether any may be symptomatic, and find that one lesion is rubbed with clothing and may itch at times. You then code CPT 17110 for the destruction of seborrheic keratoses with a diagnosis of irritated seborrheic keratosis.

Answer: Incorrect. Although it may be tempting to “save the patient money,” inducing the patient to admit to a symptom of dubious existence, and then constructing the billing based upon such data, may be construed as fraud. Furthermore, seborrheic keratoses with minor itching will not qualify as a covered service. Repeated outlier billing, as for destruction of irritated/inflamed seborrheic keratoses, can lead to a focused audit, ZPIC involvement (including interviews of patients by ZPIC auditors), and demands for refunds and/or prosecution for fraud.