Are You Submitting the Charges for Your Services Compliantly?

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Are you submitting your charges correctly and accurately to Medicare and other insurance carriers?  It is imperative that providers code their services correctly and appropriately to prevent violations of the False Claims Act (FCA).  You are violating the FCA when you knowingly submit a false claim to the government or cause another to submit a false claim to the government or knowingly make a false record or statement to get a false claim paid by the government.  Here are some illegal methods that you should avoid when submitting your charges.


Upcoding is the practice of assigning a higher-level service or procedure or reporting a more complex diagnosis than what is supported by medical necessity, facts or the provider’s documentation.  An example would be submitting an E/M code for a new patient visit for a patient’s follow-up visit.  Since Medicare pays more for a new patient visit, this would be classified as upcoding.  This also applies to using an inappropriate modifier for the E/M service, such as modifier -25, which allows for an additional payment for a service that was provided on the same day, but as a separate procedure or service.


Downcoding, on the other hand, occurs when a provider fails to provide relevant documentation details to assign a service or procedure or a diagnosis to the optimal level of specificity.  Some providers may utilize this practice (coding to a lesser-level code) to get a claim paid.  In other words, the lesser-level code is submitted to the insurance carrier due to prior knowledge that a higher-level code will be denied payment by that insurance carrier.  Downcoding is just as improper as upcoding.  And it is bad patient care since this practice can potentially harm the patient by under-documenting a diagnosis, indicating that the condition is less serious than it is.


Unbundling is the practice of submitting multiple procedure codes for a group of procedures that are covered by a single comprehensive code.  Although this can occur due to ignorance or misunderstanding of the codes, it may also be intentional and is used to maximize reimbursement.


This is the practice of sending out duplicate claims in order to get multiple payments for the one service or procedure.  The intent is to collect in excess of the applicable fee schedule.  Therefore, it is inappropriate to keep sending out claims when there is no payment from the insurance carrier.  We must find out the reason why a payment has not been made by the carrier and then follow up with a suitable action instead of just sending out multiple copies of the same claim.  And if you do get a duplicate payment from a carrier, you must refund that amount back.

Using Inappropriate Modifiers

This is the practice of appending modifiers to a CPT code to gain more reimbursement.  An example is modifier -59 (distinct procedural service, other than E/M services); it is used to indicate that a procedure or service is distinct or independent from other services that were provided on the same day.  In order for it to be legitimate, documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate injury not ordinarily encountered or performed on the same day.  To utilize this modifier for a non-distinct procedure to get a higher payment would be inappropriate.

Misuse of Provider Number

Providers should only submit claims by using his or her own provider number.  He/she should not be billing for services under another physician’s identification number.  Therefore, it is improper to bill out services for a new provider, who has joined a physician group and is waiting for approval for his/her Medicare enrollment, as locum tenens (fee-for-time compensation arrangement), utilizing the Q6 modifier.  Locum tenens is a Latin phrase that means “to hold the place of, to substitute for”.  Locum tenens billing should only be used for physicians who are covering for the regular physician who is absent for reasons such as illness, pregnancy, vacation or continuing medical education.  Additionally, locum tenens coverage only applies to a period which is no longer than 60 days.  The proper way to manage a new provider is to hold the claims for his/her services (for Medicare, you have 12 months to file from the date of service) and submit them after the enrollment process has been completed.

Physician Revenue Navigators is a premier company that provides revenue management for healthcare entities. Contact us to learn more about how we can help you bill out charges for your services compliantly.

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