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In
most cases, the drug has been used appropriately,
however the person performing the DUR has been
forced into product-centered DUR without considering
the patient past history or clinical status. Switching
to patient-centered DUR study provides more accurate
clinical status of the patient and helps in controlling
healthcare cost as well as healthcare related
services more efficiently. In this type of study,
importance is primarily given to inappropriate
utilization of medications and screening of targeted
patient-population. For example, patients who
are elderly with prior history of bone fractures
and falls may be screened for drugs that may potentially
cause additional falls and fractures or for drugs
that may adversely affect bone mass index. This
may include excessive or inappropriate use of
sedatives or benzodiazepines, which may cause
additional falls.
ANSWER
11
(a) The following coding systems, ICD-9-CM, CPT-4
, and HCPCS, were adopted as standard code sets
under the Health Insurance Portability and Accountability
Act (HIPAA). Effective October 16, 2003, all covered
entities are required to use these national coding
systems.
1.
ICD-9-CM is the official system of assigning codes
to diagnoses and hospital procedures in the United
States. Volumes 1 and 2 comprise diagnostic codes,
and Volume 3 lists certain hospital procedure
codes. ICD-9-CM is maintained jointly by the National
Centers for Health Statistics and the Centers
for Medicare and Medicaid Services as part of
the ICD-9-CM Maintenance Committee. ICD-9-CM is
modified annually to accommodate new terminology
and procedures, and to update outdated nomenclature.
ICD-9-CM will eventually be replaced by ICD-10-CM
(diagnostic codes) and ICD-10-PCS (hospital procedure
codes).
2. CPT® is a systematic coding system for
reporting medical services and procedures performed
by physicians. CPT is maintained by the American
Medical Association and is modified every year.
Revisions are usually effective for dates of service
on or after January 1 of each year. CPT also represents
Level 1 of the Healthcare Common Procedure Coding
System.
3. The Healthcare Common Procedure Coding System
(pronounced “hick-picks”) was originally
created for use under the Medicare program. Today,
HCPCS is used by virtually every payer in the
United States.
ANSWER
12
(d) All. Medical providers who bill Medicare,
Medicaid, and other Government programs use a
standardized system of numerical codes for patient
services. In this way, insurers and the Government
do not have to work out what services were provided
from numerous records or from thousands of different
types of coding or billing systems. Misuse of
these standardized codes to obtain more money
than is allowed by law is commonly termed “UPCODING”
or “UPCHARGING.”
Each Medicare billing code is tied to a particular
group of services and will eventually result in
a reimbursement to the physician or other provider
(hospital, psychologist, chiropractor, etc.) based
upon the code entered by the provider. Providers
have financial incentives to “upcode”
or increase the bill by exaggerating or even falsely
representing what medical conditions were present
and what services were provided.
For example, when a 2-minute visit for diagnosis
and treatment of an upper respiratory condition
(i.e. a cold without complications) is “upcharged”
from a very low reimbursement rate code by intentionally
using codes for a more serious ailment. Thus,
the “URI” or “upper respiratory
infection” diagnosis is altered to indicate
that the patient was suffering from a more severe
bronchitis and sinus infection, with some breathing
impairment requiring nebulizer treatment, and
the patient required a full 1-hour office visit.
In either case, whether the additional services
billed were not even provided or if provided but
not medically needed, a fraudulent “upcharge”
occurs.
Churning occurs when a physician provides a service
to a patient more frequently than is necessary
for the purpose of billing for more services.
For example, a psychiatrist may require more sessions
with the patient than are recommended for the
condition.
Unbundling or fragmentation occurs when a physician
bills separately for services that are normally
reported as one service. Medicare and Medicaid
often have special reimbursement rates for a group
of procedures commonly done together, such as
typical blood test panels by clinical laboratories.
Some health care providers seeking to increase
profits will “unbundle” the tests and
bill separately for each component of the group,
which totals more than the special reimbursement
rates.
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