Over the years, we’ve written many a blog post on risk adjustment compliance, advising our readers on ways to work successfully with this payment paradigm. And yet, almost every week, the Office of Inspector General (OIG) publishes notices regarding false claims liability for medical practices working with Medicare Advantage plans. Sadly, we’re not surprised. The most recent press release concerns a practice in Philadelphia who allegedly submitted unsupported diagnosis codes.

The codes in question are for chronic obstructive pulmonary disease (COPD) and morbid obesity (MO). Let’s look at these conditions in more detail.

COPD is a respiratory condition affecting millions of Americans. According to the Global Initiative for Obstructive Lung Disease (GOLD), diagnosing COPD requires spirometry test results within specific parameters.

Over the years, we’ve seen a COPD diagnosis conferred without spirometry because:

  • The patient is/was a smoker. Yet GOLD states that although cigarette smoke is an environmental risk factor for COPD, “fewer than 50% [of heavy smokers] develop COPD during their lifetime.” Consequently, smoking history cannot be de facto evidence of the diagnosis.
  • An imaging study, such as a CT scan or chest x-ray, showed it. COPD is not an imaging-based diagnosis although a scan may show lung changes consistent with COPD. Per GOLD, “spirometry is required to make the diagnosis.”
  • The patient is/was a smoker and is using a bronchodilator or steroid. First, these medications are used for myriad conditions, many of which are not risk adjusted. Second, per CMS guidelines, the mere presence of a medication is not clinical support for a condition.

To be sure, other pulmonary conditions also fall under the CMS-HCC model and may be diagnosed via imaging or based on signs and symptoms for a defined period of time, but not COPD.

MO is one we don’t often see mis-coded but for the PA practice, it allegedly was. Body mass index (BMI) is the determinant of conditions such as overweight, obesity and morbid obesity. To be clear, we’re specifically referring to the BMI documented on the note at the time of the visit. Under ICD-9 guidelines, MO was defined as having a BMI of 40 or above; ICD-10 removed this instructional note, which has made it possible for providers to code MO for pts with a BMI between 35.0 and 39.9 as well. However, a BMI in that range doesn’t mean MO is automatically supported. Health plan guidelines require comorbidities (usually two) that when combined with a BMI of 35+, pose a greater risk for the patient’s health and future medical costs.

This means: 1) Your practice should have an internal policy – approved by your Medical Director – that specifies which comorbidities are recognized by your practice as meeting these criteria AND provider visit notes should specify which comorbidities the patient has. This is part of supporting the condition with evidence. 2) Your providers must assess MO as they do any other condition. A proper assessment is more than a short statement that the patient was provided with a diet plan. If your patient had uncontrolled diabetes, would the provider simply say, “Take your medicine” at every visit? Or would there be an escalation of treatment options while attempting to manage the condition? Same with MO. 3) Pay attention to BMIs because they can fluctuate at every visit. This is something that billers can assist with when they review a note prior to encounter processing in order to minimize coding errors.

The PA medical group also allegedly improperly billed Evaluation and Management code 99214 and 99212 (incident to). This video explains the new AMA criteria for E/M which took effect on January 1, 2021.

It’s important for providers to understand that each instance of reporting an unsupported (diagnosis or procedure) code is considered a false claim. The US Department of Justice’s website states, The FCA provides that any person who knowingly submits, or causes to submit, false claims to the government is liable for three times the government’s damages plus a penalty that is linked to inflation. Needless to say, the financial costs can be staggering because in addition to these fines, the provider may be subject to recoupment from the plan for all unsupported codes.

Last Updated on Wednesday, 21st June 2023 9:59 pm