Who Is Responsible for Proper Coding?

In mid-August the US attorneys for the Eastern District of Pennsylvania and Delaware announced that a health care provider agreed to pay $600,000 to resolve liability under the False Claims Act, due to alleged improper billing of an electro-acupuncture device. More recently a Colorado podiatrist found himself in court. He alleged that a device maker (similar to the Pennsylvania and Delaware case) helped create a scheme to bill Medicare using improper codes that they provided to him. Interestingly, the device manufacturer was dropped from the case because the podiatrist failed to provide sufficient details over the alleged fraud.

Both of these cases involved using a surface electrode stimulator connected to acupuncture needles, which were placed percutaneously, either behind the ear or in the foot for purposes of pain control. 

As a peer reviewer for several large worker’s compensation carriers, I have seen claims in the tens of thousands of dollars by our colleagues and by pain specialists for the above procedures. The codes provided by the manufacturers at the very least misrepresent the proper use of the CPT codes.

There are four lessons to be learned here:
1) Sales representatives are paid commission and whether they provide you with accurate information or not is not their priorities. It should be yours!

2) Simply being paid for a procedure does not make the use of this or that code correct;

3) Always check reliable third-party sources, such as CMS, AMA, and APMA, for information on ICD10, CPT, and HCPCS coding. Payer websites, Facebook, and Instagram pages do not provide accurate information and are not responsible for your misadventures.

4) The manufacturer, which was supposedly your ally, is likely either nowhere to be seen in court or will be your adversary.

5)  Ultimately you are the one responsible for using the proper coding, no one else! 

—Paul Kesselman, DPM