Blogs

by Maria Seedorff, DC CPC AHFI Clinical Special Investigator at Healthcare Fraud Shield Continuous Positive Airway Pressure or CPAP therapy has become a routine treatment for those suffering from sleep apnea and other sleep-related conditions. Sleep studies are the tests used to diagnose sleep disorders, by reading biometrics (body measurements) during sleep. [1] The most common types of sleep studies are: Polysomnography - This gold-standard test "records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study. It is usually done at a sleep disorders ...

Nicholas J. Messuri, Esq., Vice President and Deputy General Counsel for Fraud Prevention & Recovery at DentaQuest, a national dental insurer with corporate offices in Boston, Massachusetts, was elected Chair of the NHCAA Board of Directors for 2016. Nick has already served NHCAA for several years and has made tremendous contributions to the Association with his innovative thinking and depth of knowledge and experiences, so naturally, I wanted to learn more. I was able to spend time with him to discuss the coming year and here’s what he had to say: Q1. Nick, congratulations on your election and welcome! You’ve mainly worked on the medical side ...

If you missed our webinar this January regarding the 2016 CPT coding changes or want a refresher on the key changes, then dig into this newsletter edition which provides just a few of the highlights. This year, there were 139 new CPT codes, 136 revised codes and 89 deleted ones. In addition, there were also new guidelines, coding tips and parenthetical instructions. Surgery Section In the surgery section there are three (3) new codes of interest used to report thoracic paravertebral block (PVB) by injection (single and additional) or continuous infusion. A paraspinous block completely desensitizes the affected spinal segment- usually ...

2016 Changes: More Prolonged Visit Codes! In February 2013, Healthcare Fraud Shield wrote an article about the Current Procedural Terminology (CPT) Prolonged service codes, CPT 99354-99359. These services are add-on codes affording providers extra reimbursement when rendering care that extends beyond the usual E/M (Evaluation and Management) service. The American Medical Association has made some revisions and additions to this range of CPT codes. Prolonged Services Revisions For example, the original descriptor of CPT code 99354 reads "Prolonged service in the office or other outpatient setting requiring ...

Healthcare Fraud Shield's Coding Q&A Healthcare Fraud Shield's Subject Matter Experts receive many emails throughout the year containing questions regarding FWA, coding and more. Healthcare Fraud Shield is dedicated to sharing information in the FWA field. As a result, below are some recent questions along with the answers shared with some of our readers: Question: Can a provider bill multiple units of CPT 75898 (Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis)[1]? Answer: The MUE limit on CPT 75898 is 1. To be able to bill multiple units, the provider ...

Canalith-Coding making you dizzy? What is Canalith? Canalith is a type of procedure aimed at helping individuals with vertigo or dizziness. The specific name of the condition often treated with Canalith is called benign paroxysmal positional vertigo (BPPV). According to the Mayo Clinic, "BPPV occurs when tiny particles called otoconia in one part of your inner ear break loose and fall into the canals of your inner ear." [1] The Vestibular Disorder Association explains the image below noting that the "Otoconia migrate from the utricle, most commonly settling in the posterior semicircular canal (shown), or ...

When the topic of patient cost forgiveness comes up in an SIU, you may initially wonder what the big deal is with cost forgiveness. This does not appear to be money that directly impacts an insurance company, and on the surface may sound like a good thing for patients that may have a financial hardship. However, once you start researching the issue a little further it becomes easier to see why it's not always as benign as it seems. Yes, for a patient that may not have enough money to cover a large deductible or coinsurance amount on a surgery or inpatient stay they may need, payment plans may be needed or the opportunity to work with a doctor or facility ...

There are many services billed to insurance companies where the time spent with the patient can impact reimbursement. These services can be found throughout various sections of both CPT and HCPCS codes including, but are not limited to evaluation and management, physical therapy, home health, nursing visits, speech therapy, and behavioral health. When time is a component of the code, the medical records should clearly indicate the amount of time spent performing the service. Let's explore the psychological testing codes which include the time component. According to the American Psychological Association (APA), psychological testing "involves the ...

Social Media, Collusion, TMI and more! Investigators utilize a combination of tools and resources to gather intelligence on potential subjects. The Internet adds another level of research accessible from any computer with an Internet connection. While Internet research can help obtain knowledge quickly, it can also contain false or misleading information. It is up to each investigator to vet the source and the details obtained. So how can the Internet help us to be better investigators? Connecting the dots Many investigations result in the identification of collusion among various actors. Payers often rely on claims ...

Check out the blog here: http://conta.cc/1IdTb5S or read below Repeat Offender? A look at Modifier 79 Modifier 79 is often overlooked as a potential area for misuse; however, investigators should keep it on their radar. This modifier is defined in the AMA CPT manual as: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional during the Postoperative Period. The individual may need to indicate that the performance of a procedure or ser vice during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures ...

What’s a Never Event? The more appropriate term for a Never Event, is Serious Reportable Event (SRE). This term was first coined in 2002 by the National Quality Forum (NQF). [1] According to the NQF, “Preventing adverse events in healthcare is central to NQF’s patient safety efforts . To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set of Serious Reportable Events (SREs). This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care.” The original list of 27 SREs ...