Healthcare Fraud Shield’s Latest Article: All You Wanted To Know About Fluoride Varnish, But Were Afraid To Ask!

Healthy gums and teeth are important, to overall health. Oral health is a predictor of overall health and wellness. The Surgeon General reports: “Dental decay is the most common chronic disease of childhood and affects a disproportionate number of low-income and minority children.” [1] According to the Centers for Disease Control and Prevention (CDC), Healthy People 2010 Final Review: [2] “Approximately 42% of children ages 2 to 11 years have dental caries in their primary teeth.”

What is Fluoride Varnish?

Fluoride varnish is a topical dental treatment, simple to apply that can help prevent tooth decay. It can slow it down or stop it from getting worse. Fluoride varnish is made with fluoride, a mineral that is proven to strengthen tooth enamel (strong outer coating on teeth).  

Once a child starts to get teeth it is recommended that preventative care including fluoride varnish are used to assist with oral health preservation. Baby teeth begin to come in about six months of age and permanent teeth at six years of age, continuing until early adulthood.

When should Fluoride Varnish be used?

The Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care Periodicity Schedule, [3] recommends the following schedule: “Age 6 months to Age 5 years.”

The American Dental Association (ADA)[4] recommends: “Varnishes must be reapplied at regular intervals with at least 2 applications per year needed for sustained benefit.”

Who can apply Fluoride Varnish?

Fluoride Varnish can be applied by trained health care providers like dentists, and primary care providers. It only takes a few minutes to apply and can be done during routine preventive health visits.

How is it billed?

Dental providers should be using dental code CDT code D1206 (Topical application of fluoride varnish).

Primary Care providers should be using CPT code 99188 (Application of topical fluoride varnish by a physician or other qualified health professional).

Most payors will have guidelines around the frequency of billing that may vary from 2-4 times per year. Make sure to be familiar with your carrier’s policies.

What to look for?

Dental claims and medical claims usually don’t run in the same claim platform.  Look for cross over billing.  i.e. dentists billing medical platform.  Additionally, watch for Dental providers who are billing D1206 (Topical application of fluoride varnish) and reporting D1208 (Topical application of fluoride).  Both codes can be used but should not be reported more than four times per year in total no matter the combination.

Primary care providers should not be reporting D1206 (Topical application of fluoride varnish) D1208 (Topical application of fluoride) as these are dental codes.

Finally, there should be an indication of high risk of caries (cavities) reported with any fluoride service code by either dentists or primary care providers. Most payors will have guidelines around the frequency of billing that may vary from 2-4 times per year.  Make sure to be familiar with your carrier’s policies.

If you have any questions or comments, please contact SIU@hcfraudshield.com.

REFERENCES

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[1] 2000 Surgeon General’s Report on Oral Health in America

[2] Centers for Disease Control and Prevention (CDC) Healthy People 2010 Final Review

[3] The Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care Periodicity Schedule

[4] American Dental Association (ADA)

ABC, 123, I mean A1C?

How many of us look at our lab results and know what all the letters and numbers mean?  It can be overwhelming to know what all of the different tests are for and why we need them. One test we hear a lot about as consumers is A1C.   A1C also goes by several other names such as hemoglobin A1C, HbA1c, glycated hemoglobin, or glycohemoglobin test.¹ 

So what is A1C?

A1C is a blood test that is used to manage diabetes, in particular Type II diabetes as well as prediabetes.  The A1C test measures the average blood sugar or blood glucose levels over the last 2-3 months.

How are the results reported?

If you are looking at your lab test results, you will see a percentage recorded for your A1C level. The higher the percentage, the higher your levels of blood sugar or glucose.   Below 5.7% is considered a normal test result, between 5.7% and 6.4% indicates a likelihood of developing diabetes and anyone with 6.5% would most likely be diagnosed with diabetes.

 

How is the test billed?

The A1C test is billed using Current Procedural Terminology Code 83036, Hemoglobin; glycosylated (A1C).  Since the test is looking at the average levels over the last 2-3 months, it would not be common to see this test billed daily, weekly or even monthly.  

 

What to look for?

Keep in mind that every patient has a different medical history which should be reviewed in context of any analysis.  It is always recommended to check your internal policies and procedures first. However, some areas of concern could be:

• Look for providers billing this upwards of 6 or more times per year
• Look for diagnoses that don’t correspond to diabetes related symptoms
• Look for excessive units per date of service
• Review medical records to determine if tests are repeated after normal results

If you have any questions or comments, please contact SIU@hcfraudshield.com.

REFERENCES

[1] What is A1C?

Healthcare Fraud Shield’s Latest Article: Let’s Talk About Modifier JW!

Let’s refresh our memories on what modifiers are and what they do.  Modifiers are extra characters that may be letters, numbers or both that are appended to either a CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) Code.  Modifiers provide additional information about equipment, service, procedure, and/or condition of a patient.  Some modifiers may also have an impact on reimbursement. 

What is Modifier JW?

Modifier JW is defined as Drug amount discarded/not administered to any patient. Effective January 1, 2017, CMS required providers to submit Modifier JW on Part B claims for the discarded material for drugs and biologicals.[1]

How is it billed?

According to CMS, This modifier should not be used for[2]:

• drugs or biologicals administered in a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC).
• claims for hospital inpatient admissions that are billed under the Inpatient Prospective Payment System
• drugs or biologicals from multi-dose or multi-use packages

Modifier JW should only be used for drugs in single dose or single use packaging.[2] If a provider administers 30 units of a 50 unit single use file and discards the 20, then the provider should bill the appropriate code with 30 units on one line with no modifier and the same code on a separate claim line with 20 units and modifier JW.   

Modifier JW should not be used when the dosage administered plus the discarded amount would be less than or equal to the billing unit.  For example, if 1 unit equals 10 mg and the provider only administers 5 mg and discards 5 mg, then the provider would submit the appropriate code with 1 unit and no modifier.

Another example provided by UnitedHealthcare in their policy is as follows:

“Example of vial size selection, the CPT/HCPCS code for Drug A indicates 1 unit = 30 mg. Drug A is available from the manufacturer in 60mg and 90mg vials. The amount prescribed for the patient is 48 mg. If the provider uses a 90 mg vial to administer the dose, the provider may only submit 2 units (rather than 3 units) as the doses available from the manufacturer allow the prescribed amount to be administered with a 60 mg vial”.[3]

What to look for?

It is important to check your respective plan policies and guidelines.  However, it is recommended to look for providers billing for this modifier excessively and for the average number of units higher per patient than other providers.  Keep in mind, many dosage amounts for drugs or biologicals are based on various guidelines including the patient’s weight and diagnosis.    The dosage amount used and the amount discard should be documented in the medical record (compounding record).  Therefore, if the dosage amount is based on a patient’s weight one could calculate the appropriate drug amount based on the information in the medical records. This information would include the physician’s order, patient’s weight and medically necessity of the treatment.

Another area of review would be to look for providers appending a modifier JW for drugs or biologicals that come in a multi-use dose or package. Crosswalk the J code to the drug’s NDC number which would provide the specific package size.

When requesting records, make sure this request includes the following components of the records:  compounding records, nurse’s infusion records, physician’s orders, progress notes and drug invoices.

If you have any questions or comments, please contact SIU@hcfraudshield.com.

REFERENCES

[1] Modifier JW

[2] CMS Guidelines-Modifier JW

[3] UHC Policy

Healthcare Fraud Shield Latest Article: Are You Seeing an Increase in Digital Medicine Billing?

In 2019, the American Medical Association (AMA) introduced two new codes related to the review and assessment of a patient’s heath record.   The AMA refers to these codes as digital medicine[1].   Several new codes were introduced relating to Remote Patient Monitoring (RPM) and Interprofessional Consultation codes. Today’s article will focus on the new Interprofessional Consultation Current Procedural Terminology (CPT) codes which are as follows:

CPT 99451 – Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time

CPT 99452 – Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes

What’s the difference?

 

There were several codes introduced in 2014 that also relate to non-contact services. The table below shows the difference between the old and new codes[2]:

CPT 99451 is written only and reported by the consultant and CPT 99452 is reported by the treating/requesting physician.

What to look for?

• Both codes are time-based so look for excessive time billed in a day
• Look for frequency of codes billed per patient, per provider
• Look for services billed separately that would be considered included. For example, according to Medicare CCI, CPT 99358 and 99359 (prolonged services without face to face contact) would not be allowed with 99451.

If you have any questions or comments, please contact SIU@hcfraudshield.com.

REFERENCES

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[1]  AMA

[2] Code Comparison

If you would like to learn more about Healthcare Fraud Shield’s analytics solution, contact us at info@hcfraudshield.com.  

Healthcare Fraud Shield’s Latest Article: Developmental Testing Code Changes

Happy New Year! With a New Year comes new codes, coding changes and of course coding challenges.   This article will focus specifically on the changes made to developmental testing.  In February 2018, Healthcare Fraud Shield wrote an article about the differences between Current Procedural Terminology Code (CPT) 96110 and 96111[1]. CPT 96111 was deleted; however, CPT 96110 remains.

2018 Codes and Descriptions

96110: Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96111: Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report.

2019 Codes and Descriptions

As mentioned above, CPT 96110 remains an active code for 2019.   Additionally, two new codes were added:

96112: Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour

+96113: Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure)

What is Developmental Testing?

It used to diagnosis developmental problems among children.   For example, according to the AAP (American Academy of Pediatrics), CPT 96111 including tests such as the Bayley Scales of Infant Development (Third Edition).[2] This test is used to “identify possible developmental delay, inform professionals about specific areas of strength or weakness when planning a comprehensive intervention, and provide a method of monitoring a child’s developmental progress.”[3]

What to look for?

• Since the new codes are time based, look for providers billing excessive time per patient, per day across all patients, and/or excessive units of the add-on code (96113).
• Look for bundled services. Evaluation and management codes can be billed along with developmental testing codes as long as the services are separate and distinct.

If you have general SIU questions or comments, please contact us at  SIU@hcfraudshield.com.

REFERENCES

1. HCFS Article
2. AAP Fact Sheet
3. Bayley Scales of Infant Development (Third Edition)

Healthcare Fraud Shield’s Latest Article: Vitamin D Deficiency

Vitamin D is often referred to as the sunshine vitamin. Who doesn’t love sunshine? Our bodies produce Vitamin D when we are exposed to direct sunlight. It converts a chemical in our skin into an active form of Vitamin D (calciferol).[1] Vitamin D can also be found in many foods such as fish, fish oils, mushrooms and more.

Why are we talking about Vitamin D?

In recent years we have seen an increase in testing for Vitamin D deficiency. While there are exceptions, most individuals do not need to be tested for Vitamin D deficiency.   Many organizations and individual health experts assert that testing for Vitamin D deficiency is not necessary.[2]

How is it billed?

These are the codes[3] you will typically see on claims:

• 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
• 82652 Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed
• 0038U Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative

When is it covered?

Check your plan’s medical policies for the symptoms and risk factors that are deemed appropriate for testing.   Many plans consider it medically necessary if patients have Chronic stage kidney disease, liver disease, osteoporosis and more.[4] According to one plan only 1 in 10 of the folks in their area have a medical reason to be tested. Additionally, the results of the test most likely will not impact treatment.[5]

What to look for?

One can adopt several simple data mining approaches to identify potential fraud, waste and abuse.

• Identify providers billing this code excessively compared to their peers
• Look for providers billing the code multiple times per patient
• Review patient diagnoses to determine if medically necessary
• Look for providers billing the same diagnosis code (vitamin D deficiency) for every patient

If you have general SIU questions or comments, please contact us at  SIU@hcfraudshield.com.

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REFERENCES

1 What is Vitamin D?

2 Medical Necessity

3 Codes

4 Policy Coverage

5 Test Results

If you would like to learn more about Healthcare Fraud Shield’s analytics solution, contact us at info@hcfraudshield.com.  

Healthcare Fraud Shield’s Latest Article: Don’t Get Sick from Flu Codes

Influenza, more commonly referred to as the “flu” is a contagious respiratory virus that can have a wide range of symptoms. In mild cases, a patient may exhibit symptoms such as fever, fatigue, body aches and sore throat. In the most extreme cases, especially in the very young or elderly, influenza can be fatal.

In the United States, although influenza viruses circulate year-round, “flu season” occurs in the fall and winter, often peaking between December and February, but can extend well beyond that[1].

Influenza Testing

There are several different tests to detect influenza. The two main types you may see most often are DNA/RNA based tests or immunoassay tests. Though both can provide relatively quick results, the immunoassay tests, also known as Rapid Influenza Diagnostic Tests (RDIT) are usually faster and can typically provide results while the patient waits. The DNA/RNA tests typically take longer and may prevent results during the same visit. The DNA/RNA tests often carry a higher associated cost.

How is it billed?

• 87502: Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types[2]
• 87804: Infectious agent antigen detection byimmunoassay with direct optical observation; Influenza[3]

What to Look For

Although testing has value under the correct clinical circumstances, according to the CDC, testing is not needed for all patients with signs and symptoms of influenza to make antiviral treatment decisions. Once influenza activity has been documented in the community or geographic area, a clinical diagnosis of influenza can be made for outpatients with signs and symptoms consistent with suspected influenza, especially during periods of peak influenza activity in the community[4].

To detect potential fraud, waste or abuse, the below analytic behaviors could be worth additional review:

• When were tests performed? Did they occur during flu season?
• Did patients receive BOTH DNA/RNA and RDIT tests within the same time frame? What order?
• Did many/most patients receive testing?
• Did most patients receive the DNA/RNA? What was the clinical rationale?

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[1] CDC

[2,3] AAPC Coder

[4] Guidance for Clinicians on the Use of Rapid Influenza Diagnostic Tests

Healthcare Fraud Shield’s Latest Article: Medical Evaluation and Management Codes Billed by Dentists

The American Dental Association develops and publishes the Current Dental Terminology (CDT) code set. According to the American Dental Association (ADA), “The purpose of the CDT Code is to achieve uniformity, consistency and specificity in accurately documenting dental treatment”.[1]

In a typical dental office, a patient is seen for preventative and problem focused services. While most dental offices utilize the CDT oral evaluation codes, some prefer to use the CPT outpatient/office visit procedure codes. There are monumental differences between the two classes as outlined below:

 

CDT office visit codes

 

D0120 – Periodic oral evaluation

D0140 – Limited oral evaluation -problem focused

D0145 – Oral evaluation for a patient under the age of three years of age and counseling with primary caregiver

D0150 – Comprehensive oral evaluation

D0160 – Detailed and extensive oral evaluation – problem focused, by report

D0180 – Comprehensive periodontal evaluation-new or established patient

Most oral evaluations include periodontal screening and may require interpretation of information acquired through additional diagnostic procedures. A brief history is sometimes taken as well. You can refer to your CDT book for further procedure code descriptions.

 

Evaluation and Management CPT codes

CMS’ Evaluation and Management Documentation Guidelines[2] states “The code sets to bill for E/M services are organized into various categories and levels. In general, the more complex the visit, the higher the level of code you may bill within the appropriate category…The three key components when selecting the appropriate level of E/M services provided are history, examination, and medical decision making.”

For example, if the dentist bills procedure code 99213, the documentation must include an expanded problem focused history. The history component includes a brief description of history of present illness (HPI), and a problem pertinent review of systems (ROS). The documentation must also include an expanded problem focused examination which is defined as a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Lastly, the documentation must include medical decision making of low complexity. Low medical decision making is comprised of a limited number of diagnoses, a limited amount or complexity of data to be reviewed, and low risk of complications or co-morbidity. Refer to the E/M Documentation Guidelines for definitions of each of these levels of key components.

 

What to look for

When billing an office visit for dental services, be mindful of what was performed during the visit. CPT E/M services require a lot more documentation to bill and, the services for a mid to high level E/M procedure code are generally not performed during a dental visit.  Investigators and analysts should look for:

• Excessive comprehensive evaluations
• Excessive medical E/M codes compared to peers
• Excessive high level medical E/M codes

If you have general SIU questions or comments, please contact us at  SIU@hcfraudshield.com.

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[1] CDT

[2] Evaluation and Management Documentation Guidelines

If you would like to learn more about Healthcare Fraud Shield’s analytics solution, contact us at info@hcfraudshield.com.  

Healthcare Fraud Shield’s Latest Article: Don’t Feel the Pressure of Wound Therapy Billing

Negative Pressure Wound Therapy (NPWT) is a technique used to aid healing of burns, acute and chronic wounds to include, without limitation, diabetic wounds, pressure wounds, surgical wounds and burns. In negative pressure wound therapy, the provider uses an electrical pump to apply controlled subatmospheric pressure through a sealed dressing, which creates a vacuum around the wound to remove fluids and infectious materials and to promote healing.

Considerations
There are many considerations that vary from payer to payer. Many payers will have specific medical policies governing when NPWT would be acceptable, what interventions should be attempted prior to NPWT and what requirements are necessary to support ongoing therapy.

In many cases, ongoing therapy will need to demonstrate that the therapy is efficacious. This typically requires that the treating provider perform or supervise dressing changes, and report on the wound size and characteristics.

How is it billed?
It is billed using HCPCS (Healthcare Common Procedure Coding System) Code E2402: Negative pressure wound therapy electrical pump, stationary or portable.This code covers the supply of an electric pump used to provide negative pressure wound therapy.

What to look for
One of the most common red flags concerns how long the patient is using NPWT. A patient that extends beyond four (4) months of NPWT, may be worth additional review. This will be especially true if the provider has a pattern of a disproportionately high number of patients being billed for atypically long periods (4+ months).

Some Behaviors and KPIs to Examine
1) Frequency: How long is the course of NPWT?
2) Density: What percentage of patients have atypically long durations of NPWT?
3) Connectivity: What other services and/or conditions does the patient have? Prior to NPWT? Concurrent with NPWT?

If you have general SIU questions or comments, please contact us at SIU@hcfraudshield.com.

If you would like to learn more about Healthcare Fraud Shield’s analytics solution, contact us at info@hcfraudshield.com.

Healthcare Fraud Shield’s Latest Article: Developing a Method to Uncover Abnormal Billing Behavior

As with past articles from Healthcare Fraud Shield, future articles will focus on specific schemes to look for, where we will examine specific schemes or issues supported by precise codes, be they procedures, diagnoses, modifiers, or DRGs (Diagnosis Related Groups) associated with high risk behaviors.

However, in this article, we want to take a step back and discuss methodologies to analyze data, so that any behavior, known, or not, will raise to the surface, and predicate additional review.  In many future articles, we will relate many of these concepts to methods to uncover the specific schemes discussed.

Developing a Methodology

One of the best ways to uncover “outliers” is to first understand the areas of risk. Think about your successful cases, or recent cases in the news. What common threads did they have? Once you isolate on these “macro” level behaviors, you can begin to look for them, wherever they may hide.

You should develop a method that accounts for the major behaviors you identified. Going through your cases like a checklist is one way to begin to formulate your behavior list. Keep in mind the behavior list is not the list of allegations, it is more the why behind it. For example, what is upcoding? Billing for a higher level of service than what was provided. How/why does that happen? Many factors can impact the degree to which a service is potentially up codded. Some of these include, specialty, condition, and even geography. Your method should answer the why and the how.

One approach you may consider is the below Suspect Behavior Profile When you examine your cases, you will probably find that many of those cases exhibited one or more of the following behaviors driving the scheme. This is just one approach, feel free to use this as a springboard, add to it, subtract from it, make it work for you.

Frequency

Something is happening too frequently. Most commonly, it could be repeat visits, but it can be more hidden, such as suspicious duplication of procedures over time.

Density

Density looks at how clustered or concentrated behaviors are. For example, a very simple density issue is too many patients in a day. However, as another example, it could look at things such as abnormal numbers of patients from a specific employer group.

Intensity

Intensity is analogous to the upcoding mentioned above. On the simple side, it can be procedural upcoding, billing a higher level of service within a group of related procedures. It can also include examples that include a modifier, or diagnosis that is added to a claim (think DRG) that increases the payment.

Velocity

Velocity measures the degree to which a behavior is increasing or decreasing. “Spike” detection often considers only positive changes, but abnormal negative changes can be just as enlightening. Change detection methodology is important to uncover spikes and dips within payments, patient volume and services.

Connectivity

The last of the five (5) behaviors in the profile is connectivity. This looks at relationships between attributes. For example, we often hear of “link analysis” which identifies relationships between provider and patients. However, in addition, and often overlooked, there are “connections” between many other attributes. Examples could include procedure to procedure, procedure to gender, procedure to specialty, etc.  

Take Away

• Dissect some of your prior cases and think about the behaviors that manifested as potential suspicious behaviors you would like to detect in a more strategic approach
• Develop specific KPIs for each of those behaviors. Some examples include:
  • Frequency: Visits/Patient
  • Density: % of Patients
  • Intensity: Average Level of Service
  • Velocity: % Increase
  • Connectivity: % of Total
• Look for outliers at the provider, procedure and diagnosis level for those KPIs. That could be indication of issues that require additional review
• Conduct additional review, and validate/refine the KPIs that are working best

If you have questions specific to this article, you may contact Jim McCall at jmccall@hcfraudshield.com.

If you have general SIU questions or comments, please contact us at  SIU@hcfraudshield.com.

If you would like to learn more about Healthcare Fraud Shield’s analytics solution, contact us at info@hcfraudshield.com.