OMT billing? DO to pay Medicare back 379K

[futuredoc15]

William J. Garrity, who does business as Suffield Primary Care and as Family Medicine, will pay $379,764 to reimburse Medicare for activity from 2002 to 2009, a statement from the U.S. attorney's office said.
U.S. Attorney David B. Fein said Garrity treats patients with musculoskeletal disorders using a medical procedure known as osteopathic manipulative treatment, or OMT. Most of the time, prosecutors say, Garrity billed Medicare for both OMT and for an office visit the same day. "Medicare does not normally allow additional payments for evaluation and management services performed by a provider on the same day as a procedure because it is expected that most procedures involve some pre-procedure and post-procedure care that is part of the payment for that procedure," the prosecutors' statement said.
See article here:
http://www.courant.com/health/connecticut/hc-suffield-doctor-fine-0401-20110331,0,4325198.story

Comment: I guess this means you can not bill a patient for OMT on the same day as an office visit.

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[DbDan]

Sounds fairly ridiculous to me. I'd like to see how he was billing them for it. Don't allow for evaluation as well as procedure? Guess you can't give those stitches to that open wound the same day that the patient is in your office...

I worked for a DO who regularly billed for level 2 and 3 visits + OMT, I see no problem with it. It is a billable procedure just like anything else that a physician does. It sounds to me like he was billing something incorrectly or billing for OMT + follow-up visits from procedures that are normally global visits (not billed) or something.

 

[Pansit]

William J. Garrity, who does business as Suffield Primary Care and as Family Medicine, will pay $379,764 to reimburse Medicare for activity from 2002 to 2009, a statement from the U.S. attorney's office said.
U.S. Attorney David B. Fein said Garrity treats patients with musculoskeletal disorders using a medical procedure known as osteopathic manipulative treatment, or OMT. Most of the time, prosecutors say, Garrity billed Medicare for both OMT and for an office visit the same day. "Medicare does not normally allow additional payments for evaluation and management services performed by a provider on the same day as a procedure because it is expected that most procedures involve some pre-procedure and post-procedure care that is part of the payment for that procedure," the prosecutors' statement said.
See article here:
http://www.courant.com/health/connecticut/hc-suffield-doctor-fine-0401-20110331,0,4325198.story

Comment: I guess this means you can not bill a patient for OMT on the same day as an office visit.

Yes...it is a bit archaic, but you have to work with the system. So if they came in for a regular visit, and you decide OMT should be performed, then have them come back for another appointment. Usually doctors only allot 15 minutes for a regualr visit, so it is easy to explain to the patient that they need another appointment on another day for a procedure. That way you can bill for the regular office visit and the procedural visit. Billing for both on one day makes it seem like the patient came in for a procedure and was ALSO billed a regular visit unnecesarrily

 

[group_theory]

Yep, that's the rule that you (and all other doctors) have to work with if you are a Medicare provider, or if the insurance companies follow the same rules as medicare.

You cannot bill separately for an office visit and a procedure unless you clearly establish that the procedure is above and beyond the other services provided.

A patient comes to you with a chief complaint of warts, which you cryofreezed. You should not bill for an office visit (let's say cpt 99212) and for the wart removal (cpt 17110). Either bill the visit as an office visit or as a wart removal but not both (either one is fine, but the wart removal is reimbursed significantly higher than the office visit).

But if your patient comes in for an annual women's health exam, requesting refills of her birth control, and at the same office visit, requesting a flu shot, then you can bill for the women's health exam AND flu shot since the flu shot is considered above and beyond the other services provided. But in order to do that, you have to use a E/M modifier (in this case, modifier 25). Modifier 25 allows you to append your office visit to include another "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service"

You can bill for the women's health exam with the appropriate modifier (99395-25), and the flu shot (90471).

So for DOs and OMT - it gets a little bit more confusing. Most insurances and medicare now accepts OMT as a procedure that isn't bundled into the initial evaluation. When the CPT codes for OMT first came out, many insurers were refusing to pay for OMT, saying that it was bundled into the initial E/M code for the office visit. With further clarifications from the HFCA and CMS, it was established that OMT does not require separate diagnosis for an E/M and OMT on the same day.

If you see an established patient for tennis elbow, and decided to do OMT, you can bill for the office visit with the appropriate modifer (99213-25) and then bill for the OMT (98925). The key is using modifer 25 appropriately.

If you are a surgeon seeing a patient post-operatively in clinic, and decide to remove the sutures - usually you can't bill for the suture removal since that's part of the reason why she was visiting you in the office and is considered bundled with the visit. *the entire postop visit might not even be paid for by most insurance, since it is considered part of the global fee they paid the surgeon for the surgical procedure)

Confused yet? Remember, if you don't get this right, and all the nuances of coding, billing, and documentation, then you just commited insurance fraud (and you too can be iin the newspaper with a state attorney general or US attorney general accusing you of insurance/medicare fraud )

Or you can just skip the entire thing and go cash-only 😀

 

[DbDan]

Thanks for the write-up group_theory. Very informative.

Moral of the story: Know the proper way of billing very very well or hire an experienced biller to do it for you when you start a practice.

 

[ShyRem]

Billing is the bane of every physician's existence. Insurance companies regularly change the rules in order to get out of paying for services and seem to deliberately make billing complicated with complicated rules just to say you didn't follow the "new rules" which are even at times retroactive.

 

[JaggerPlate]

Yep, that's the rule that you (and all other doctors) have to work with if you are a Medicare provider, or if the insurance companies follow the same rules as medicare.

You cannot bill separately for an office visit and a procedure unless you clearly establish that the procedure is above and beyond the other services provided.

A patient comes to you with a chief complaint of warts, which you cryofreezed. You should not bill for an office visit (let's say cpt 99212) and for the wart removal (cpt 17110). Either bill the visit as an office visit or as a wart removal but not both (either one is fine, but the wart removal is reimbursed significantly higher than the office visit).

But if your patient comes in for an annual women's health exam, requesting refills of her birth control, and at the same office visit, requesting a flu shot, then you can bill for the women's health exam AND flu shot since the flu shot is considered above and beyond the other services provided. But in order to do that, you have to use a E/M modifier (in this case, modifier 25). Modifier 25 allows you to append your office visit to include another "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service"

You can bill for the women's health exam with the appropriate modifier (99395-25), and the flu shot (90471).

So for DOs and OMT - it gets a little bit more confusing. Most insurances and medicare now accepts OMT as a procedure that isn't bundled into the initial evaluation. When the CPT codes for OMT first came out, many insurers were refusing to pay for OMT, saying that it was bundled into the initial E/M code for the office visit. With further clarifications from the HFCA and CMS, it was established that OMT does not require separate diagnosis for an E/M and OMT on the same day.

If you see an established patient for tennis elbow, and decided to do OMT, you can bill for the office visit with the appropriate modifer (99213-25) and then bill for the OMT (98925). The key is using modifer 25 appropriately.

If you are a surgeon seeing a patient post-operatively in clinic, and decide to remove the sutures - usually you can't bill for the suture removal since that's part of the reason why she was visiting you in the office and is considered bundled with the visit. *the entire postop visit might not even be paid for by most insurance, since it is considered part of the global fee they paid the surgeon for the surgical procedure)

Confused yet? Remember, if you don't get this right, and all the nuances of coding, billing, and documentation, then you just commited insurance fraud (and you too can be iin the newspaper with a state attorney general or US attorney general accusing you of insurance/medicare fraud )

Or you can just skip the entire thing and go cash-only 😀

So the guy just didn't use a modifier appropriately?

 

[group_theory]

So the guy just didn't use a modifier appropriately?

Keep in mind that we do not have all the facts of the case in front of us.

It may very well be that he didn't bill appropriately (and billed for two seperate codes without the appropriate modifier). While it may look innocent, in the eyes of the government and also with private insurance, it's considered fraud (and will demand restitution with penalty fees). Insurances routinely deny payments for something that simple.

Or the guy may have billed appropriately but didn't have the appropriate documentation to support billing at certain levels (or documentation to justify using OMT). Documentation issues are big reasons why physicians and physician groups get into trouble with the government and private insurance.

Or the guy may have billed appropriately, and have appropriate documentation, but the prosecutors have misinterpreted the rules and laws governing medicare healthcare billing (since it is VERY complex). Remember, we're hearing the government side to this case only. The case must still go to trial, and a jury or judge may decide that the doctor did everything right and is legal. Remember, just because the IRS accuses someone of tax fraud does not necessarily mean that tax fraud occurred - the judge or jury may find that no fraud occurred. It's good PR to hold a press conference to show you are going after insurance fraud (or Medicare/Medicaid fraud), but you seldom see prosecutors hold press conferences to go "mea culpa, we were wrong in the interpretation of the rules and regulations and have unjustly prosecuted the doctor"

We just don't have the facts of the case.

 

[olivedjazzer]

Or you can just skip the entire thing and go cash-only 😀

Bingo Bango. 😉

 

[facetguy]

Keep in mind that we do not have all the facts of the case in front of us.

It may very well be that he didn't bill appropriately (and billed for two seperate codes without the appropriate modifier). While it may look innocent, in the eyes of the government and also with private insurance, it's considered fraud (and will demand restitution with penalty fees). Insurances routinely deny payments for something that simple.

Or the guy may have billed appropriately but didn't have the appropriate documentation to support billing at certain levels (or documentation to justify using OMT). Documentation issues are big reasons why physicians and physician groups get into trouble with the government and private insurance.

Or the guy may have billed appropriately, and have appropriate documentation, but the prosecutors have misinterpreted the rules and laws governing medicare healthcare billing (since it is VERY complex). Remember, we're hearing the government side to this case only. The case must still go to trial, and a jury or judge may decide that the doctor did everything right and is legal. Remember, just because the IRS accuses someone of tax fraud does not necessarily mean that tax fraud occurred - the judge or jury may find that no fraud occurred. It's good PR to hold a press conference to show you are going after insurance fraud (or Medicare/Medicaid fraud), but you seldom see prosecutors hold press conferences to go "mea culpa, we were wrong in the interpretation of the rules and regulations and have unjustly prosecuted the doctor"

We just don't have the facts of the case.

Documentation is crucial to getting paid and to fending off post-payment audits (like this one). My guess is his documentation didn't support what he was billing. Post-payment audits suck and will cost you money, win or lose.

 

[Jamers]

William J. Garrity, who does business as Suffield Primary Care and as Family Medicine, will pay $379,764 to reimburse Medicare for activity from 2002 to 2009, a statement from the U.S. attorney's office said.
U.S. Attorney David B. Fein said Garrity treats patients with musculoskeletal disorders using a medical procedure known as osteopathic manipulative treatment, or OMT. Most of the time, prosecutors say, Garrity billed Medicare for both OMT and for an office visit the same day. "Medicare does not normally allow additional payments for evaluation and management services performed by a provider on the same day as a procedure because it is expected that most procedures involve some pre-procedure and post-procedure care that is part of the payment for that procedure," the prosecutors' statement said.
See article here:
http://www.courant.com/health/connecticut/hc-suffield-doctor-fine-0401-20110331,0,4325198.story

Comment: I guess this means you can not bill a patient for OMT on the same day as an office visit.

This really isn't surprising at all. Most of the FP doctors I worked with would have their patients come in for an "omm visit" and then a "medical visit/office visit" later.

 

[JaggerPlate]

This really isn't surprising at all. Most of the FP doctors I worked with would have their patients come in for an "omm visit" and then a "medical visit/office visit" later.

Sounds easier all around to me.

 

[Powdermonkey]

Sounds easier all around to me.

For you, maybe, but it's tougher for the patient because they have to get off of work again, lose wages again, take time to drive to see you again, etc. It's stupid that you can't bill for OMT during an office visit, or at least in a less complicated fashion.

 

[JaggerPlate]

For you, maybe, but it's tougher for the patient because they have to get off of work again, lose wages again, take time to drive to see you again, etc. It's stupid that you can't bill for OMT during an office visit, or at least in a less complicated fashion.

Actually, it's probably better for the patient all around too. Yes, they have to take more time off, but it's far more likely that if an office does regular checkups/visits 4 days a week and then has patients come back for an all OMM day on the 5th day that the doctor is going to be far more focused and offer a more comprehensive treatment compared to busting it out in 20 seconds while worrying about some modifier code in the back of his head the entire time.

Health care is comprised of three pillars - cost, quality, and access. In the real world, you can usually pick one or two out of three, but not all of them. Does the patient want it now with low quality? Or later, but at a higher quality?

I guess there is no right or wrong answer, but I'd personally rather be more focused and offer more effective care. Who knows how that pans out though.

 

[Powdermonkey]

Actually, it's probably better for the patient all around too. Yes, they have to take more time off, but it's far more likely that if an office does regular checkups/visits 4 days a week and then has patients come back for an all OMM day on the 5th day that the doctor is going to be far more focused and offer a more comprehensive treatment compared to busting it out in 20 seconds while worrying about some modifier code in the back of his head the entire time.

Health care is comprised of three pillars - cost, quality, and access. In the real world, you can usually pick one or two out of three, but not all of them. Does the patient want it now with low quality? Or later, but at a higher quality?

I guess there is no right or wrong answer, but I'd personally rather be more focused and offer more effective care. Who knows how that pans out though.

The patient population I'm working with right now is very poor. So for them taking time off of work at a job that they are very luck to even have at all is tough for them. I just think that if you can fit it in now, do it. I do agree that an OMM centered visit will allow to be better focused though.

 

[JaggerPlate]

The patient population I'm working with right now is very poor. So for them taking time off of work at a job that they are very luck to even have at all is tough for them. I just think that if you can fit it in now, do it. I do agree that an OMM centered visit will allow to be better focused though.

Yeah, I definitely see the merit of integrating it all at once as well. Plus, I agree that it's a pain you can't just bill for both, but I do think that if you use the modifier properly (just from what I've read here, etc) that you'll at least be compensated for the manipulation.