Not Following the Rules Costs Chiropractor $5 Million

September 1st, 2020 - Wyn Staheli, Director of Research
Categories:   Chiropractic   Audits/Auditing   Compliance   DME|Supplies|Equipment   HCPCS Coding  

Every healthcare office needs to know and understand the rules that apply to billing services and supplies. According to the false claims lawsuit, code L8679 “Implantable neurostimulator, pulse generator, any type” was billed for a device which was really P-stim, a form of acupuncture. According to court documents, a P-Stim is an electric acupuncture device that is attached to the ears of the patient using two small pads whereas code L8679 describes a product surgically implanted into a patient.

This is not the first time that the OIG has gone after healthcare providers and organizations for inappropriately billing this particular device. In September 2019, another doctor was ordered to pay $178,000 for inappropriately billing for P-stim using the same code (L8679). In fact, the OIG press release stated that “[t]he investigation into others involved in this scheme remains ongoing.” There are several key points that providers need to understand.

A Scheme is a Scheme

Currently, Medicare will only reimburse a chiropractor for chiropractic manipulative treatment. This particular doctor, in order to get around that rule, worked with a consulting company to basically ‘rent’ a medical director and Family Nurse Practitioner from them in order to bill services/supplies which Medicare does not allow a chiropractor to bill. While integrated medical practices are a great way to promote chiropractic care, this is an example of the entirely wrong way to integrate. Integration should be more about ensuring that patients receive the appropriate care needed instead of a way to simply get around the rules.

According to court documents, “On March 27, 2017, Defendants, in consultation with Company-1, rolled out a bonus program to incentivize the improper billing of HCPCS L8679. Under the bonus program, Defendants paid NP’s, through Company-1, $100 per P-Stim “treatment.” When money is being transferred between businesses this way and bonuses are being offered for non-work, that is a kick-back scheme.

Reimbursement Rates As a Guide

Another red flag is that third-party payers, including Medicare, do not pay far above the value of a service or supply. According to court documents, “While the P-Stim devices typically cost between $300 and $500, Medicare typically reimburses between $5,000 and $6,500 for HCPCS L8679.” In fact, the current Medicare national unadjusted allowed amount for this service is $7,917.79. Does that really sound like a disposable throw away device that costs less than $500 to purchase from the manufacturer? 

Review Manufacturer Information

While HCPCS codes generally cover more than a single device, manufacturers generally know how they should be categorized or coded. It should be noted that in this case, the device manufacturer’s website stated “... [i]t is our understanding that Medicare and some commercial insurance companies are not covering electroacupuncture or auricular vagus nerve stimulation devices…” This should have been another red flag.

Summary

When you file a claim, you are certifying that you understand the rules and that you have followed them. It is your responsibility to know payer policies and follow the rules. Be sure you are conducting regular self-audits. See the ChiroCode DeskBook for a self-audit template.

Court documents identify the p-stim devices as “Stivax, NeuroStim, ANSiStim, E-Pulse, and NSS-2 Bridge.”  If you have billed code L8679 for any of these products, contact a healthcare attorney immediately about how to self-disclose and mitigate penalties for filing false claims.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Reporting Drug Wastage with Modifier JW and NEW Modifier JZ
August 15th, 2023 - Aimee Wilcox
Modifier JW has been around since 2003 with changes in Medicare policies to ensure standard utilization in 2017; however, because of a continued lack of reporting consistency, Medicare has created and implemented policy related to reporting a new modifier, JZ. How does this impact Medicare reimbursement and why is this modifier so important?
Finding Patterns of Complexity in the Medical Decision Making (MDM) Table
August 8th, 2023 - Aimee Wilcox
Changes to the Medical Decision Making (MDM) Table in 2023 reflect the work performed in the facility setting in addition to the work involved in Evaluation and Management (E/M) scoring in other places of service. Taking the time to really look closely at the MDM Table and identify patterns in wording and scoring helps coders to understand scoring in an easier way.
Seven Reasons to Standardize Medical Records
July 18th, 2023 - Aimee Wilcox
The standardization of medical records offers numerous benefits for healthcare systems, providers, and patients. By ensuring interoperability, improved workflows, better patient safety, supporting research endeavors, and optimizing resource allocation, standardized records contribute to improved efficiency, quality of care and especially patient outcomes. Here are seven reasons to standardize medical records.
Advancements in Coding Hospital Observation Care Services in 2023
July 4th, 2023 - Aimee Wilcox
Hospitals are increasingly adopting innovative solutions to improve patient care and optimize processes and many of these solutions follow immediately the recent CPT and Medicare coding changes.  In 2023 coding of hospital observation care services underwent significant changes enabling healthcare providers to accurately document and bill for the sick or injured patient that requires a higher level of medical services between the emergency room care and hospital admission. This article explores the key changes in coding hospital observation care services and their impact on healthcare delivery.
Be Aware — Emergency Department Visits Under OIG Scrutiny
June 20th, 2023 - Wyn Staheli
Every year the Department of Health & Human Services Office of Inspector General (OIG) creates an official work plan giving everyone a heads up as to what they are going to be reviewing. The 2022 Work Plan stated that they would be reviewing claims for Evaluation & Management services provided in an emergency department (ED) setting.
OIG Audit Reveals Diagnosis Reporting Problems Affecting Risk Adjustment Scoring
June 15th, 2023 - Wyn Staheli
The Office of the Inspector General (OIG) recently published their Spring 2023 Semiannual Report to Congress. This report contained some diagnoses reporting issues that all providers need to be aware of. They focused on several groups of diagnoses that they considered “High-Risk” for being miscoded. Several states were included in the report and the types of errors for all can be generally grouped into several categories.
Documenting for Suture and Staple Removal E/M Add-On Codes
May 30th, 2023 - Aimee Wilcox
Historically, the 10-day and 90-day global periods would include the patient's follow-up Evaluation and Management (E/M) services and any dressing changes or staple/suture removal related to the surgery; however, following a closer analysis of these and other surgery codes, the decision was made to make significant revisions to these codes to ensure proper reporting.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association