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* True or false claim? Must a DME supplier meet all of the 21 supplier standards?
* Coding for autolytic wound debridement
* Pay-per-view article: The ABCs of auditing for inaccurate DRG assignments

Compliance Monitor, April 18, 2003

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True or false claim? Must a DME supplier meet all of the 21 supplier standards?

Q: Can a durable medical equipment supplier (DME) be held criminally liable under the False Claims Act for failing to meet some of the Department of Health and Human Services' 21 DME standards?

A: As a special condition for payment, durable medical equipment (DME) suppliers must certify that they're in compliance, and will continue to be in compliance with the supplier standards (42 C.F.R. 424.57(c)). Therefore, if you file a claim to Medicare or Medicaid while you're out of compliance with any of the supplier standards, this may constitute a false claim.

The civil False Claims Act only covers offenses that were committed with actual knowledge that the claims were false, or if you were deliberately ignorant of the truth or falsity of the claim, or if you recklessly disregarded whether the claim was true or false (31 USC 3729(b)(1)-(3).

In order for someone to prove criminal liability for false claims, the claims must be submitted by the supplier who knows "such claim to be false, fictitious, or fraudulent," according to federal law (18 USC 287). If suppliers know that they are out of compliance with any of the 21 supplier standards at the time that they submit claims to the government for payment, they may be held civilly and criminally liable.

This question was answered by Richard M. Tuten, Esq., president of Tuten Consulting Services, Inc.

Go to "The ABCs of auditing for inaccurate DRG assignments" for the rest of this article. The cost is $10. Subscribers to the online version of Health Care Auditing Strategies have free access to this article. Subscribers to the print edition can find it in their April issues.

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You can read this article—and much more—in the entire April issue of Health Care Auditing Strategies. Your cost: Three stories for only $30! You get a step-by-step guide to effective EMTALA compliance audits, and SNFs will learn how self-audits can head off trouble. Choose between a PDF or HTML version for just $30. Online subscribers have free access to this issue. Print newsletter subscribers can find it in their mailboxes.

Q: We are an acute care hospital with an outpatient wound care program. Should we bill autolytic wound debridement as selective debridement (code 97601) or non-selective debridement (code 97602)? Autolytic wound debridement is not an enzyme process, but it is new and the clinical procedural terminology (CPT) code book does not address it.

A: One resource to consult isCPT Changes 2001: An Insider's View, published by the American Medical Association Press. It is intended as a reference guide to understand the changes in the CPT book. Commentary on page 205 includes the following:

Non selective debridement, as described by code 97602 includes these conditions:

• enzymatic
• autolysis or other selected agents
• wet

Therefore, choose 97602 to report autolytic wound debridement.

This question was answered by Charla Prillman, CPC, CHCO, senior associate, PricewaterhouseCoopers, LLP.

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