This $2 million settlement announcement illustrates the importance of keeping up with — and following — coding and billing gudiance from AMA and your Medicare contractor.
What happened? According to the announcement released Oct. 3, the practice regularly reported moderate sedation services that failed to meet the intraservice time requirement of at least 16 minutes. (Until this year moderate sedation services involved 30 minutes of intraservice time or at least 16 minutes under the CPT manual's half-time rules for time-based codes.)
New York Spine & Wellness routinely billed for moderate sedation services when its physicians spent less than the required 16 minutes with the patient. These moderate sedation claims were submitted in connection with claims for underlying therapeutic and/or diagnostic services for which New York Spine & Wellness also billed and was paid. Although New York Spine & Wellness utilized the services of an independent billing company, New York Spine & Wellness retained the contractual obligation to code its services accurately.
The DOJ noted that the AMA issued detailed guideance on time-based codes in its CPT Assistant in October 2011. The DOJ also noted the information was confirmed by the MAC for New York.
in February 2012 in an explanatory article released to its listserv and also maintained on its website for a period of approximately one year.
In addition, the practice apparently ignored warnings from its billing company, even after the practice was audited by a private payer.
In or about January 2015, a private insurance company rejected two of New York Spine & Wellness’s claims for moderate sedation services because, as described by New York Spine & Wellness’s billing company, the “Medicare 16 minute span rule to bill [the] code” was not satisfied. In mid-June 2015, the same private insurance company performed an audit and rejected New York Spine & Wellness’s claims for moderate sedation services where the documentation did not support that the procedure lasted more than 16 minutes. The billing company advised New York Spine & Wellness to review the audit findings concerning moderate sedation services. New York Spine & Wellness continued to bill for moderate sedation services after mid-June 2015 without the required 16 minutes of face-to-face time.
According to the DOJ, the practice continued to submit claims for moderate sedation services that didn't meet the time limit until it was contacted by the DOJ "in connection with this investigation."
Whether the case would have had a different outcome if the practice had started following the rules in 2015 must remain a matter of speculation. But all practices should note that the DOJ stressed the importance of keeping up with coding and billing guidelines.
Providers should have policies and procedures in place to ensure that they are familiar with applicable billing requirements before submitting claims.
A final note: The DOJ expressed appreciation for the practice's cooperative attitude. This makes us wonder how much the practice would have paid if it hadn't cooperated.