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Understanding false claims and fraudulent billing

Staff Development Weekly: Insight on Evidence-Based Practice in Education, November 5, 2004

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A patient has undergone major surgery for trauma and is transferred to the intensive care unit (ICU) for monitoring. Dr. Stevens, who is following the patient, but who did not perform the surgery, feels that it is appropriate to bill an ICU visit for that day because the medical decision making is more complex than usual.

Annie, a hospital coder, does not think the medical record documentation supports an ICU visit. However, the physician continues to insist that she should bill for an ICU visit. She decides to listen to the doctor's judgment.

Question: What do you do?

Answer: Annie should not bill for the ICU visit if the medical record documentation does not support it. A visit is only considered critical care if the patient is unstable, and the physician must assess, manipulate, and support circulatory, respiratory, central nervous, metabolic, or other vital system functions to prevent or treat single or multiple organ system failure.

Editor's note: The above case scenario is from the online course "Understanding false claims and fraudulent billing." For more information on this and other courses in our Compliance library, go to www.hcprofessor.com and click on Compliance. 

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