Never underestimate the importance of compliance when it comes to medical billing services. This seems to be especially so for dermatology practices as there have been several notable cases of misrepresentation in dermatology billing, including claims involving up-coding that have come under closer scrutiny. The American Academy of Dermatology (AAD) specifically states in its Professional and Ethical Standards for Dermatologists that “we should not engage in fraudulent billing or coding…it is unethical…to submit codes reflecting a higher level of service or complexity than those…actually required.”
A tale of two practices
Practice #1 – A multi-specialty practice was utilized by a retired dermatologist already familiar with proper coding procedures. When reviewing her bill, she found that the CPT codes being used were all for “99214” (‘detailed’ visits) although no such ‘detail’ or examination took place. No visit lasted more than 10 minutes and no consequential decisions were made.
The office manager, who used to work for the patient/doctor, admitted that the 99214 CPT was used for all visits, regardless of complexity levels, resulting on numerous upcoding violations.
Practice #2 – A Florida dermatologist was investigated for charging Medicare $49 million over six years, for actions including the following: violating billing rules requiring the doctor’s physical presence, misdiagnosis, improper coding incentives, and possible practice beyond licensure. The doctor had claimed to “cure” skin cancer through radiation “therapy” (that he was not qualified to perform) as well as unnecessary biopsies. He was reported by another physician who treated the misdiagnosed patients.
The above cases involve compliance risks to watch for, including:
- Billing for impossibly long days (i.e.: 26 hours)
- Failing to follow the supervisions rules
- Incentivizing code overuse
- Performing outlier services that are not justifiable
- Improperly using multiple removal CPT codes
Getting the Basics: Start With the History
Using Evaluation and Management (E/M) coding (also referred to as “level of service”, or LOS) as examples when used in conjunction with follow-up as well as new-patient visits, we’ll code as follows:
1. A 30 y/o male presenting with a 2-week history of an itchy red facial rash (‘chief complaint’), not taking any new medications, rash not improved with OTC lotions. There is no history of tobacco; patient has history of asthma. ROS was negative for new growths or fever.
The above includes a chief complaint, with a total of 5 HPI points: duration, severity, location, quality and modifying factors. There are 2 past-history points (tobacco use and asthma) and 2 ROS (skin and constitution.)
This could be coded as either 99202 or 99203 E/M code as it has a detailed level history as well as based on exam complexity and decision-making.
2. Chief complaint: acne patient follow-up (visit); HPI –patient returns with face and back acne not improved with topical tretinoin. Negative for tobacco, ROS dry skin. With a chief complaint, 2 HPI points for location and modifying factors, 1 past history and 1 ROS.
The history in this case would be considered an expanded problem focused history. To bill for a 99213 level visit, the physician would also need to have documented either an expanded physical exam or low-complexity medical decision-making.
Ensure Ethical Coding With a Professional Billing Service
Given the financial penalties and other consequences for a practice caught in the act of questionable billing, it is more critical than ever to avoid even the appearance of fraud with dermatology billing and coding claims.
Since 2002, M-Scribe has been helping dermatology practices avoid submitting coding errors and questionable documentation on claims, resulting in higher reimbursement rates while fully complying with all ethical and regulatory considerations.
Contact our experienced counselors for a free analysis of your dermatology practice’s needs and goals at 770-666-0470 or email me for more detailed information.