Page 29 - FPGEE Management Q&A Book

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Misuse of these standardized codes to obtain more component of the group, which totals more than
money than is allowed by law is commonly termed the special reimbursement rates.
“UPCODING” or “UPCHARGING”.
25.(c) The program of palliative and supportive care
Each Medicare billing code is tied to a particular services that provides physical, psychological, social,
group of services and will eventually result in a and spiritual care for terminally ill persons, their
reimbursement to the physician or other provider families, and other loved ones is defined as hospice
(hospital, psychologist, chiropractor, etc.) based care.
upon the code entered by the provider. Providers
have financial incentives to “upcode” or increase Hospice services are available in both the home and
the bill by exaggerating or even falsely representing inpatient settings. It normally includes pain relief
what medical conditions were present and what and support services, physician and nursing services
services were provided. coordination, in-home care, therapy, and
counseling.
For example, when a 2-minute visit for diagnosis
and treatment of an upper respiratory condition To be eligible for hospice, an individual must be
(i.e. a cold without complications) is “upcharged” diagnosed as terminally ill (i.e. life expectancy of six
from a very low reimbursement rate code by months or less without intervention). Palliative care
intentionally using codes for a more serious is any form of medical care or treatment that
ailment. concentrates on reducing the severity of the
symptoms of a disease or slows its progress rather
Thus, the “URI” or “upper respiratory infection” than providing a cure. It aims at improving quality
diagnosis is altered to indicate that the patient was of life, and particularly at reducing or eliminating
suffering from a more severe bronchitis and sinus pain.
infection, with some breathing impairment
requiring nebulizer treatment, and the patient 26.(d) The partial filling of a prescription for a
required a full 1-hour office visit. In either case, controlled substance listed in Schedule II is
whether the additional services billed were not permissible if the pharmacist is unable to supply the
even provided or if provided but not medically full quantity called for in a written or emergency
needed, a fraudulent “upcharge” occurs. oral prescription and he makes a notation of the
quantity supplied on the face of the written
Churning occurs when a physician provides a service prescription, written record of the emergency oral
to a patient more frequently than is necessary for prescription, or in the electronic prescription
the purpose of billing for more services. For record.
example, a psychiatrist may require more sessions
with the patient than are recommended for the The remaining portion of the prescription may be
condition. filled within 72 hours of the first partial filling;
however, if the remaining portion is not or cannot
Unbundling or fragmentation occurs when a be filled within the 72-hour period, the pharmacist
physician bills separately for services that are shall notify the prescribing individual practitioner.
normally reported as one service. No further quantity may be supplied beyond 72
hours without a new prescription.
Medicare and Medicaid often have special
reimbursement rates for a group of procedures A prescription for a Schedule II controlled substance
commonly done together, such as typical blood test written for a patient in a Long Term Care Facility
panels by clinical laboratories. Some health care (LTCF) or for a patient with a medical diagnosis
providers seeking to increase profits will documenting a terminal illness may be filled in
“unbundle” the tests and bill separately for each partial quantities to include individual dosage units.

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