First, let’s introduce you to Healthcare Fraud Shield’s new Director of Prepayment Review, Alexandria Denton. Alex’s work has spanned across industries in healthcare, hospitality, and holistic well-being. The trajectory of humanity and addressing social needs have been primary areas of focus throughout her life and work. Having worked in healthcare for the past 22 years has been as much about finding ways to give back as it is about moving forward with her personal and professional growth. In that work, it became apparent to Alex that healthcare fraud impacts our nation’s GDP significantly and the overall health of our nation’s healthcare system. The vast sums of dollars lost to healthcare fraud impacts people’s lives and the care people need. Alex has spent the last 13 years as a chief strategist and architect in designing solutions to end healthcare fraud & abuse as part of making a healthier healthcare system for all. Alex is truly inspired that she gets to work on solving these problems at Healthcare Fraud Shield now. As Alex has said, the people and their products are incredible.
The Value of Prepayment Software and Claims Reviews
Prepayment Claims Review is when claims billed by healthcare providers are pended by a payor’s claims processing system for claims review before payment is made but after the service has been provided. An important detail to note is that services provided to members are not disrupted. Payments made to providers are examined either through data analytics, clinical review – with or without medical records – to ensure what is billed is appropriate, actually occurred, and was necessary.
There are already plenty of audit types in healthcare. What is the value of prepayment claims review?
There are several key and important reasons prepayment review is a vital tool that payers want to include in a comprehensive program integrity system. Healthcare fraud happens in real time. A critical aspect of protecting healthcare programs and payers is protecting the dollars before they go out the door while also identifying schemes and potentially fraudulent activities as they occur. While the traditional retrospective investigative approach is still an integral and necessary function, stopping suspect claims before they are paid is vital in impacting the growing fraud, waste, and abuse (FWA) crisis. Further, investigators often want to know what occurred last week versus what occurred several years ago. Prepayment review also avoids costly, lengthy, and often unsuccessful payment recoupments with other types of audits.
Most importantly, prepayment efforts can help potentially save lives. According to Johns Hopkins (JAMA, 2019), “Patients treated by providers found to have committed fraud and abuse were more likely to die, require emergency hospitalization”.i
Healthcare Fraud Shield’s pre-payment detection system, PreShield is uniquely designed as an integrated component within the FWAShield platform and our Prepay Services. PreShield allows for real-time prepay rule detection and the ability to leverage analytics, trends and outputs using PostShield, the post-payment fraud detection module. PreShield is also integrated with CaseShield, the case tracking tool. This information allows a plan or government agency to take more decisive action and provides deeper insights into the scope and patterns of fraudulent schemes. The built-in workflow creates additional efficiencies, allows for greater tracking and reporting of results.
Fraud happens NOW. Inquire today to learn how you can proactively prevent fraud and abuse, save lives, and millions of dollars that can go towards enhancing your member services and program. If you have any questions or comments, please reach out to SIU@hcfraudshield.com.
According to the Center for Disease Control (CDC):
Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe. With mild impairment, people may begin to notice changes in cognitive functions, but still be able to do their everyday activities. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently.[i]
Cognitive impairment not only impacts victims of these symptoms, but also those around them. Patients with Alzheimer’s disease and other dementia related diseases experience cognitive impairment resulting in frequent doctor visits and hospital stays. Those experiencing impairment will likely need an assessment. According to the Alzheimer’s Association, “Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition. Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition. For these services, see the appropriate evaluation and management (E/M) code”[ii]
How is it Billed?
In January 2018, the American Medical Association added Current Procedural Terminology (CPT) code 99483. According to Medicare, CPT 99483, replaced HCPCS G0505. The description for CPT 99483 is as follows[iii]:
Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements:
Cognition-focused evaluation including a pertinent history and examination,
Medical decision making of moderate or high complexity,
Functional assessment (e.g., basic, and instrumental activities of daily living), including decision-making capacity,
Use of standardized instruments for staging of dementia (e.g., functional assessment staging test [FAST], clinical dementia rating [CDR]),
Medication reconciliation and review for high-risk medications,
Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s),
Evaluation of safety (e.g., home), including motor vehicle operation,
Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks,
Development, updating or revision, or review of an Advance Care Plan,
Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (e.g., rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support.
Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver.
What to look for?
According to the Alzheimer’s Associationii, physicians, nurse practitioners, clinical nurse specialists and physician assistants may perform this assessment, however, review any specialists billing significantly more than their peers or who typically bill this service at all. Don’t forget to check their subspecialties.
Ensure all the elements of the service are performed, otherwise an E/M may be the more appropriate service.
Look at the percentage of a provider’s patient population receiving this service and how often (the Alzheimer’s Association states the service should be reported more than once every 180 days)ii.
Review the diagnoses to see if the correspond to the service and are deemed appropriate.
Unbundling this assessment from other services on the same day.
An example of the type of activity monitored by Healthcare Fraud Shield is in the following alert:
[2547-01] – UNBUNDLING, COGNITIVE ASSESSMENT AND CARE PLAN SERVICES: This Alert identifies providers billing cognitive assessment and care plan services in conjunction with E/M services, psychiatric diagnostic procedures, brief emotional/behavioral assessments, psychological or neuropsychological test administrations, health risk assessment administrations, or medication therapy management services for the same patient on the same day, as this is considered unbundling.
Acetaminophen is arguably one of the most common medications as it is the main ingredient in Tylenol. Acetaminophen is found in several over the counter and prescription medications, including, but not limited to: Actifed, Alka-Seltzer Plus, Benadryl, Co-Gesic, Contac Excedrin, Fioricet, Lortab, Midrin, Norco, Percocet, Robitussin, Sedapap, Sinutab, Sudafed, TheraFlu, Unisom PM Pain, Vick’s Nyquil and DayQuil, Vicodin, and Zydone.[1] There are over 100 products that contain acetaminophen.[2] Since acetaminophen is so common, many of us are unaware of the damage it can cause when too much is consumed.
What is Acetaminophen Toxicity?
Acetaminophen Toxicity occurs when the volume ingested is considered to be a toxic dose potentially causing damage to the liver. According to MedlinePlus, adults should not ingest more than 3,000 mg of a single-ingredient acetaminophen in a given day and even less if they over 65 years old.[3]
What are the symptoms?
According to the Merck Manual, if the overdose is substantial enough there are four stages of symptoms:
Stage 1: Within a few hours the person may vomit
Stage 2: 24-72 hours the person may experience nausea, vomiting and abdominal pain, but blood tests show the liver is functioning abnormally
Stage 3: 3-4 days vomiting becomes worse. The liver is functioning poorly, jaundice and bleeding may develop. In some instances, the kidneys may fail, and the pancreas may become inflamed.
Stage 4: After 5 days, the person either recovers or experiences failure of the liver and other organs, which may be fatal.
Is there a treatment?
According to WebMD, “The antidote to acetaminophen overdose is N-acetylcysteine (NAC). It is most effective when given within eight hours of ingesting acetaminophen. Indeed, NAC can prevent liver failure if given early enough. For this reason, it is absolutely necessary that acetaminophen poisoning be recognized, diagnosed, and treated as early as possible”. Some studies also suggest that activated charcoal can be used as an antidote as well. [4] In some instances a liver transplant may be needed.
What to look for?
Since many pain medications include acetaminophen, many patients who may be drug seekers or are being overprescribed may be unaware of the potential effects. Look for:
1) Acetaminophen quantities across all medications prescribed to each patient in a given day
2) Identify outliers by prescriber, member, and pharmacy
Healthcare Fraud Shield’s (HCFS) software complements our AI with Alerts. HCFS deployed Alert [5152-01] – PATIENT HARM, ACETAMINOPHEN TOXICITY: This Alert identifies members taking on average 4,000mg of acetaminophen in a given day based on pharmacy data.
What happens when a service performed on a patient is split or shared among more than one provider? I’d like to introduce you to a new modifier – modifier FS. According to AAPC Coder, modifier FS indicates that “the service was a split or shared evaluation and management (E/M) visit”.[1]While the modifier was created for Medicare, other payors may adopt this modifier as they see fit.
How do I properly use modifier FS?
Only use for Evaluation and Management (E/M) Services performed and shared by both a physician and non-physician practitioner (NPP)
The physician and NPP should be part of the same provider group, but no longer required to be of the same specialty[2]
The services should be performed in a facility setting only
The shared visit (per CMS), except for critical care, should be reported under whomever performed the substantial portion of the service. What does most mean? It means more than 50% of the total time spent OR, and this is an interesting OR, whomever performed and documented the entire history, exam or MDM. Therefore, whomever billed it must have conducted one of those components in its entirety.[3]
Split or shared visits are no longer allowed in an office setting, even if they meet incident-to rules, they are facility only so check your places of service.
What to look for?
Provider excessively billing modifier FS
More than one provider billing modifier FS for the same service
Inappropriate place of service
Upcoding, does the reason for the visit warrant the level of code billed?
Has time been documented? Does the time count as qualifying time?
Did one of the practitioners have face-to-face (in-person) contact with the patient?
Lately, it feels like every week there is a new procedure code, but do you pay attention to new place of service codes? Most are familiar with Place of Service 02, but there was a description update. Place of Service 02 is now called Telehealth Provided Other than in Patient’s Home with description of:
The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology. (Effective January 1, 2017, Description change effective January 1, 2022, and applicable for Medicare April 1, 2022.)1
The newest Place of Service code to enter the arena is Place of Service 10 which is labelled Telehealth Provided in Patient’s Home. The full description is as follows:
The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology. (This code is effective January 1, 2022, and available to Medicare April 1, 2022.)2
The main difference between the two codes is the location of the patient. Place of Service 02 the patient is NOT at home while Place of Service 10 should only be used for when patients ARE at home. While the changes became effective January 1, 2022, they do not apply to Medicare until April 1, 2022.
According to CMS Transmittal 110453 that while the modification of POS Code 02 and the creation of POS Code 10 are effective in the National POS code set effective January 1, 2022, Medicare contractors received instructions regarding how to process claims with these codes starting April 4, 2022, so that Medicare would align with existing Telehealth claims processing policy, as well as be considered HIPAA compliant.
What to look for?
Check other claims billed for the member that day, what was the POS listed on that claim? Was it possible to bill either POS 02 or 10 for that patient?
What services were rendered? Are these services eligible for telehealth reimbursement?
Is the provider eligible to deliver telehealth services?
If documentation for the visit is provided, does it meet the same requirements as an in person visit?
Is the correct POS being used? Services provided in the patient’s home should not be billed with POS 02 per the new code changes. Check with your payors policy for the implementation date.
Don’t forget to append any applicable modifiers to your telehealth services!
You may asking yourselves, what Modifier? Well, in September 2021, the AMA CPT Editorial Panel agreed on the acceptance of a new modifier, Modifier -93. The code was published to the AMA website December 31, 2021. Due to the late addition of the code, many folks may not be aware of it because it will not be in the AMA code files or books until 2023 even though it is effective January 1, 2022.
Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
What should I know about this Modifier?
Let’s carve out some of the key words/sections and their meanings:
Synchronous means real-time
Telephone/Audio-Only means no video communication
Must meet the key components and/or requirements of the same service when rendered via a face-to-face interaction means this must show the same service would/coud have been rendered in person.
What to look for?
With any new code of any kind we want to look for potential abuse so we should pay close attention to:
Providers billing it excessively
Frequency of billing per member
Services performed and billed with this code that could not possibly meet the requirements if it had been performed in a face-to-face interaction
Healthcare Fraud Shield is monitoring this new Modifier very closely with a new alert:
[2527-20] – OUTLIER, MODIFIER 93: This Alert identifies providers excessively billing modifier 93 when compared to their peers as they may not be meeting the key components and/or requirements of the same service when rendered via a face-to-face interaction. (PEER COMPARISON)
In recent years there has been a change in how some emergency care services are delivered. There continue to be hospital-based emergency departments with typical ground and air ambulances delivering patients with serious illnesses including myocardial infarction, traumatic injury and stroke. At the same time we have seen an increase in free-standing emergency room facilities.
The American Medical Association Access to Emergency Services Policy H-130.970 recognizes the following:
“(A) Emergency services should be defined as those health care services that are provided in a hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily function; or (3) serious dysfunction of any bodily organ or part.”[1]
Since the onset of the COVID-19 period there has been a trend of increasing use of complex emergency department (ED) evaluation and management (E&M) procedure coding, with diagnosis codes that do not immediately indicate an emergency department level of care might be needed.
The American Medical Association (AMA) Current Procedural Terminology (CPT) has five levels of ED E&M services, defined by the five CPT codes in the range 99281-99285.[2] Each level of ED E&M service requires all three key components of history, examination and medical decision-making (MDM) to “meet or exceed the stated requirements” for the level of service reported.[3]
AMA CPT code descriptions for these ED E&M codes include a statement about the patient’s presenting problem. For the two highest level codes the presenting problems are usually of high severity:
CPT code 99284 description states, “Usually the presenting problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.”
CPT code 99285 description states, “Usually the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.”
Recent trends reflect increased use of complex ED E&M procedure codes (99284-99285), billed with or without CPT modifier CS (Cost sharing waiver), and with possible COVID-19 related diagnosis codes, including:
Z03.818 Encounter for observation for suspected exposure to other biological agents ruled out)
Z11.59 Encounter for screening for other viral diseases
Z20.828 Contact with and (suspected) exposure to other viral communicable diseases
As detailed above, the use of Emergency Department E&M procedure codes typically require services beyond COVID-19 screening and lab testing (which may be performed by a separate lab provider).
Potential schemes
Use of only COVID-19-related screening or exposure-to diagnosis codes and billed with complex ED E&M procedures (99284-99285).
Use of complex ED E&M codes (99284-99285), with screening or exposure-to diagnoses, when there are no other lab or diagnostic tests.
Excessive complex E&Ms per day emergency room, with COVID-19 related diagnosis codes, may be an indicator of upcoded E&Ms and/or billing for services not rendered. This is especially applicable when the provider performs “drive-thru” COVID-19 testing billed with complex ED E&Ms.
Complex ED E&M procedures billed for the same patient, with COVID-19 related diagnosis codes, for multiple dates of service.
Complex ED E&M procedures, with COVID-19 related diagnosis codes, billed for multiple members of the same family on the same date of service.
Billing for long-term electroencephalograms (EEGs) may feel intimidating, but it doesn’t have to be. Read on to understand how to break it down.
An EEG is a test of brain waves or the electrical activity of the brain. It is performed by attaching multiple electrodes to the scalp, which in turn detect electrical charges associated with brain cell activity.[1] This type of test is used in the evaluation of epilepsy, brain lesions or tumors, Alzheimer’s disease, narcolepsy, and other disorders.
EEGs are divided into routine and long-term services, including some code variations for ambulatory EEGs. For this discussion we’ll focus on long-term EEG/VEEG (Electroencephalogram with video), which is defined as two hours (120 minutes) or longer. The CPT codes used for EEG/VEEG billing are within the range 95700-95967 Special EEG Testing Procedures.[2] New American Medical Association (AMA) Current Procedural Terminology (CPT) codes for EEGs were released, effective 1/1/2020.
If you are billing or auditing services prior to that date, be sure you are using the applicable code set. Long-term EEG/VEEG includes three coding components:
First there is setup of the continuous recording equipment to the patient, which is performed by an EEG technologist. This activity is billed with CPT code 95700 EEG Continuous Recording. In addition to setup, this procedure code includes patient education and takedown of the equipment after the test. This procedure code is billed once per recording period.[3]
Next is monitoring of the EEG/VEEG test itself. This activity is performed by an EEG technologist, who also reviews the data that is collected and provides a technical description of the test. This is the technical component of the EEG/VEEG. CPT code range 95705-95716 Long-term EEG Monitoring is used to report these services. For this technical component, code selection is based on[4]:
With or without video
Length of recording time
Level of monitoring (unmonitored, intermittent, continuous)
Finally, the test results are interpreted and reported by a physician or other qualified healthcare professional. CPT code range 95717-95726 Long-term EEG Monitoring is used to report this professional component. Code selection for this part of EEG/VEEG is based on:
With or without video
Length of recording time
Timing of report (periodically throughout the test or upon completion)
CPT Section Specific Guidelines provide a helpful aid (shown above) for selecting codes for these three EEG/VEEG coding components. Be sure to use this resource when billing or auditing long-term EEG/VEEG codes.
Possible schemes:
Providers billing significantly more EEG/VEEGs than their peers may indicate billing for services not rendered. However, ensure each provider’s specialty is recorded correctly for accurate peer comparison.
Patients with no claim history from the referring or ordering provider may be an indication of services that are not ordered, not necessary or not performed.
Frequent or exclusive use of CPT code 95716 may reflect upcoding within CPT code range 95705-95716 (monitoring by EEG technologist) for a higher level of technical component.
Billing CPT code 95700 (EEG/VEEG setup) without monitoring (technical component range 95705-95716) or interpretation and report (professional component range 95717-95726) could be an indication of billing for services not rendered or misrepresentation of services.
Billing EEG/VEEG setup (95700) and monitoring (95705-95716) without professional interpretation and report (95717-95726) may indicate there was no need for the testing or the service was not performed. Keep in mind EEG setup and technologist services may be billed by a different provider than the one billing for interpretation and report. Be sure to query for all billed services for the member and date of service.
Healthcare Common Procedure Coding System (HCPCS) codes that start with the letter T are typically used by Medicaid agencies, Managed Care Organizations (MCO) who administer Medicaid programs. HCPCS code T1013 is described as”… Sign language or oral interpretive services, per 15 minutes…[1] This code can be used for patients who either do not speak English or who use sign language as their form of communication.
Beneficiaries who need interpretive services should contact their appropriate state agency or Managed Care Organization (MCO) to learn more about coverage, the process, requirements, standards for the interpreters and more. Many private health insurers offer free language and interpreter services to their commercial plan members. For example, effective 2012, New York Medicaid (both fee-for-service and managed care) will reimburse for interpretive services.[2]
Documentation Requirements:
As always, check with your respective agencies and plans, but for New York Medicaid beneficiaries, interpreter services should be:· Documented in the medical record· Provided during the medical visit· The interpreter should be employed by or contracted with a Medicaid Provider· Services my be in person or via telephone[3]
According to Blue Cross and Blue Shield of Minnesota and Blue Plus, “Interpreter services provided to Blue Cross subscribers must be rendered by a registered and rostered interpreter with proper certification (in accordance with Minnesota State Statute Sec.144.058”.)[4]
What to look for?
1) Excessive time billed for these services as they are time-based codes.
2) The qualifications for the interpreters; i.e.: Do they meet or not meet any necessary requirements?3) What other services that were billed for these patients on the same day, which is to look for potential unbundling of services.
If you have billed, paid or audited laboratory services there is a good chance you have encountered PLA codes, those alpha-numeric procedure codes ending in “U”. According to the American Medical Association (AMA), “Proprietary Laboratory Analyses (PLA) Codes are an addition to the Current Procedural Terminology (CPT) code set approved by the AMA CPT Editorial Panel. They are alpha-numeric CPT codes with a corresponding descriptor for labs or manufacturers that want to more specifically identify their test.”[1]
Each quarter AMA CPT accepts applications for new PLA codes. Those applications are processed, and the PLA number is assigned. The code numbers and descriptors are released quarterly. For example, on July 1, 2021 AMA CPT released seven new PLA codes 0248U to 0254U. These codes will be included in the CPT® 2022 publication.[2] In addition, PLA code revisions and deletions are detailed in the quarterly report.
PLA for COVID-19
During the COVID-19 period, new PLA code descriptions related to COVID-19 testing are being reviewed and processed in an expedited manner. The codes are published within a few weeks of application, rather than waiting for the quarterly AMA CPT PLA report.
COVID-19 related PLA codes recently published or revised include:
0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
0223U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed
0225U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific DNA and RNA, 21 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RJNA targets, each analyte reported as detected or not detected
0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)(Coronavirus disease [COVID-19]), ELISA, plasma, serum
0240U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected.
0241U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected.
COVID-19 PLA concerns to look for:
Beware of duplicate PLA codes, where more than one manufacturer has proprietary tests for the same targets. For example, PLA code 0202U (BioFire® Respiratory Panel 2.1) and PLA code 0223U (QIAstat-Dx Respiratory SARS-CoV-2 Panel) are identified by CPT as having identical clinical descriptors (duplicates).[3]
Watch for PLA codes that are a duplication of CPT Category I codes. For example, PLA CPT code 0240U and CPT code 87636 both describe testing for the same three targets.
0240U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected.
87636 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique
Similarly, PLA CPT code 0241U and CPT code 87637 both describe testing for the same four targets.
0241U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected.
87637 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique
Pay close attention to PLA panel codes billed with single lab test(s) billed for the same day that may duplicate one or more of the panel target(s). Note the PLA descriptions that indicate “each pathogen reported as detected or not detected” and verify the billed codes and pathogens are supported by corresponding lab reports.
First, let’s introduce you to Healthcare Fraud Shield’s new Director of Prepayment Review, Alexandria Denton. Alex’s work has spanned across industries in healthcare, hospitality, and holistic well-being. The trajectory of humanity and addressing social needs have been primary areas of focus throughout her life and work. Having worked in healthcare for the past 22 years has been as much about finding ways to give back as it is about moving forward with her personal and professional growth. In that work, it became apparent to Alex that healthcare fraud impacts our nation’s GDP significantly and the overall health of our nation’s healthcare system. The vast sums of dollars lost to healthcare fraud impacts people’s lives and the care people need. Alex has spent the last 13 years as a chief strategist and architect in designing solutions to end healthcare fraud & abuse as part of making a healthier healthcare system for all. Alex is truly inspired that she gets to work on solving these problems at Healthcare Fraud Shield now. As Alex has said, the people and their products are incredible. 
Healthcare Fraud Shield 
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