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Fraud or Abuse? You Make the Call on Coding Mistakes

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Let’s begin with a reminder of the definitions of fraud and abuse.

Fraud — Intentional deceptive act intended to obtain a benefit to which a person is not entitled. Examples of Medicare fraud are:

  • Billing for services or supplies not provided;
  • Incorrect reporting of diagnosis or procedures to increase Medicare payments;
  • Claims for non-covered services billed as covered services;
  • Changing claims history records to get payments;
  • Use of another’s Medicare card to get medical care provided for a different beneficiary.

Abuse — An incident or practice by a health care provider that is inconsistent with accepted sound medical, business or fiscal practices that directly or indirectly creates unnecessary costs to the Medicare program. Examples of Medicare abuse are:

  • Over-utilization of medical services, including duplicate billings;
  • Claims for services that are not reasonable and necessary;
  • Breaches of assignment provisions;
  • Exceeding the “limiting charge” for non-par providers;
  • Violations of the Medicare “participating agreement.”

As reported to the Academy, Medicare is currently auditing the following coding mistakes. Some are the result of focused medical review audits, others from whistle blowing cases. Auditors will determine if these errors are a result of coding mistakes or an intentional act.

  1. Billing the Medicare patient for the supply of punctal plugs.
  2. Billing fluorescein angiography per eye when pathology is found in only one eye.
  3. Coding 92250 fundus photography when actually performing 92135 OCT.
  4. Performing 92083 visual field right eye on Monday and left eye on Wednesday and billing the inherently bilateral service each day.

Note: Year 2002 data reveals ophthalmology practices inappropriately billed for Schirmer’s test with CPT code 95060 (mucous membrane test) more than 10,000 times, at $13.45 per test.

Did you know? AAOE members get two free, practice-specific answers to coding questions each year one of many benefits of membership.

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About the author: Reprinted from a previous AAOE The Coding Bulletin, written by Sue Vicchrilli, COT, Coding Executive for the American Academy of Ophthalmic Executives.