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5 providers bleed cash after DOJ catches venous sufficiency coding snafu

Investigators and prosecutors continue to use their coding knowledge to wring big settlements from practices. These tactics have left four physician practices poorer by an average of $218,465, the U.S. Attorney’s Office for Maryland announced on March 16.

Combined with a settlement by Baltimore-based St. Agnes Health System, those providers will pay a total of $943,767.48 to settle allegations that flowed from the way they reported venous sufficiency studies.

According to the press release:

In their practices, each of these providers had occasion to administer tests to patients to assess the venous sufficiency in the lower extremities. As part of this process, they performed a venous Doppler duplex examination. The purpose of this examination was to determine if there were blood flow issues including deep vein thromboses in the patient’s legs. They billed Medicare under CPT 93970 for this work.

Billing records showed that each billed for an additional test using CPT 93965. CPT 93965 references an older, different technology, one that has generally been replaced by the CPT 93970 technology. Upon inquiry by the U.S. Attorney’s Office and the HHS Office of Inspector General, each agreed that the billing of CPT 93965 was incorrect.

93965 (Noninvasive physiologic studies of extremity veins, complete bilateral study [eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmograph]) was deleted at the end of 2016. During that year Medicare paid about $122 per test. The fee for 93970 (Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study) was about $200.

It could have been worse. The practices didn’t have to admit guilt or go through the expense and trouble of a trial -- and, best of all, they weren’t hit with the higher punitive fines that would have stemmed from losing a case.

And it’s easy to understand how a practice might have been confused by the reporting requirements for the codes. The descriptors are similar and there were no bundling edits to stop practices from reporting both services for the same patient on the same day.

But as many coding-driven settlements show, practices have little room for error when it comes to coding errors.

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