Physician Practice

MASS-ive settlements for new/established patient coding errors

Physician Practice Insider, June 26, 2017

Two medical centers in Massachusetts will pay more than $700,000 to settle allegations that they upcoded claims when they failed to follow the rules for new and established patients.

The HHS Office of Inspector General (OIG) accused UMass Memorial Medical Center and Boston Medical Center (BMC) of billing outpatient clinic visits for established patients with certain E/M codes for new patients (99203-99205). There's a significant difference in revenue for those codes and the corresponding established patient codes (99213-99125). In the Boston metropolitan area, Medicare pays an average of $47.90 more for new patient visits reported by a facility than the established codes.

It can be difficult for providers to keep track of who is new according to guidelines in the CPT manual. That task gets much harder when multiple locations share a tax ID number. However, the two settlements indicate that the OIG expects practices to follow the rules, and it will expect a check from practices that don't. 

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