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)

Code Sequencing Chapter 15 OB Visits
February 13th, 2023 - Chris Woolstenhulme
Sometimes payer guidelines differ from the official guidelines, this can be confusing, let’s look at a sequencing priority for example in Chapter 15: Pregnancy, childbirth, and the Puerperium (o00-o9A). the guidelines tell us how to code based on the provider's documentation, in addition, it is important to know Chapter 15 codes are never to be used on newborn records, only on the maternal record. Find-A-Code will sequence codes according to the ICD-10-CM guidelines first.
Is the End Really Near?
February 7th, 2023 - Chris Woolstenhulme
What happens once the COVID-19 emergency declarations have ended?
Will 2023 Be the Year of Outsourced Medical Billing?
February 3rd, 2023 - Find-A-Code
Many healthcare providers have chosen to keep medical coding and billing in-house. From HIPAA compliance to the complexity of ICD-10 codes, it has just been easier to keep track of things by not outsourcing medical billing or coding. But things are changing. So much so that 2023 could be the year that outsourced services finally take over.
Three Things To Know When Reporting Prolonged Services in 2023
January 31st, 2023 - Aimee Wilcox
The Evaluation and Management (E/M) changes made in 2021 and again in 2023 brought about new CPT codes and guidelines for reporting prolonged services. Just as Medicare disagreed with CPT in the manner in which prolonged service times should be calculated, they did so again with the new 2023 changes. Here are three things you should know when reporting prolonged services for all E/M services.
The Curious Relationship Between CPT Codes and Actual Treatments
January 30th, 2023 - Find-A-Code
Common sense seems to dictate that medical billing codes, like CPT codes for example, are only considered after medical treatment has been provided. After all, the codes are simply a representation of diagnosed conditions and treatment services provided – for billing purposes. But there is a curious relationship between these codes and actual treatments.
Why Medical Billing Codes Are Critical To Healthcare Delivery
January 30th, 2023 - Find-A-Code
Medical coders play a critical role in determining how healthcare delivery is reported for record keeping and billing purposes. Likewise, the codes they know so well are equally critical. They have been around for decades. They were originally developed and implemented to make reporting and billing easier in a healthcare system that was becoming incredibly more complex. The system is even more complex today.
Why Knowing Medical Terminology Makes Coding Easier
January 27th, 2023 - Find-A-Code
You are excited about beginning your training as a professional medical coder. You're expecting to pass the exam and earn your certification. The future is looking bright until, as you are perusing the educational material, you suddenly realize you're going to have to learn medical terminology.



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