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Reliance on Training on YouTube Resulted in $3.9 Million in Fraudulent Billing

April 27, 2021
Documentation, Billing, & Coding By Deborah Alexander, Director

On March 10, 2021, the U.S. Department of Justice (DOJ) released a notice from the Southern District of Texas titled “Chiropractor charged with falsely billing for procedure learned via YouTube”. The civil complaint alleges $3.9 million in fraudulent billing to the Medicare and Tricare programs were paid to the provider, who admitted their staff received training and guidance via YouTube.

 

fraud payment

 

What Are the Allegations?

The provider allegedly billed for the implementation of neurostimulator electrodes, which are typical surgical procedures conducted in an operating room. The alleged treatment procedures being conducted applied inexpensive devices used for electro-acupuncture. The complaint alleges the provider was aware of Medicare and Tricare’s local coverage determinations non-coverage of these services yet proceeded. It is also alleged the provider disregarded claims submission warnings from employees and outside billing companies of a fraud alert.

Risk Considerations?

As a consultant, LW Consulting, Inc. (LWCI) is asked frequently how to appropriately bill for treatments not covered by various payers within the LCDs or Medical Practice Guidelines (MPG). As I read this DOJ notice, I could not help but think of this through the physical therapy lens. In recent years, “dry needling and cupping” have become a routine practice in outpatient therapy and coordinated wellness centers, but confusion exists on the appropriate billing practices. Therapy providers have asked these questions routinely:

  1. “Can I use 97140 to bill for dry needling or cupping?” – The answer is “no” based upon the American Medical Association (AMA) CPT code description for 97140: manual therapy techniques (e.g. Mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, every 15 minutes. Providers are reading articles by “experts” to code dry needling under 97140, when in fact it does not fit the CPT description.
  2. “Can I use 97139 or 97039 to bill for dry needling or cupping?” – Prior to the Dry Needling CPT being launched by AMA with an effective date of January 1, 2020, therapists could accurately report dry needling using these codes; however, Dry needling should not be billed if the payer clearly states it is a non-covered service. Effective January 1, 2020, CPT 20560 and 20561 were introduced, and now there is clarity where dry needling minutes are to be allocated within our documentation.

Where Do I Start When Adding a Service to My Practice?

  • Seek out the advice of a coding and billing expert, not YouTube or your colleague providing the same service in your hometown. YouTube or a colleague’s advice may not be accurate. The revenue risk for an overpayment far exceeds the costs of seeking expert coding and billing guidance.
  • Do not attempt to bill for a service not covered by bundling those minutes under the incorrect CPT code. We have supported providers who came under audits where Tricare identified this practice. The audits identified overpayments and the practice ending up on a 100% pre-payment documentation review for 6 months. Ask yourself if you can afford to not be paid until your documents are reviewed.
  • Keep in mind, if one payer identifies your practices, that payer can communicate with other agencies and payers.
  • If you, your staff, or your biller identify a possible fraudulent billing practice, do not continue to disregard the alert, as that poses a tremendous risk regarding “willful neglect.” It can and most likely will lead to a whistleblower situation.

How Can LWCI Help?

  • LWCI has Certified Professional Coders on staff to assist with these types of questions.
  • LWCI conducts routine coding and billing audits for therapy providers, chiropractic, physicians, dentists, labs, and more. LWCI has the right expert to assist you.
  • LWCI can also provide coding and billing training across the post-acute care continuum, including therapy, chiropractic, and physician practices, in private practice and within health systems.

 

Do you have additional questions? Set up a 15-minute discussion with one of our experts, Deborah Alexander, Director, CHC, CHPC, PMP, DPT, MED, STC, CSCS.

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