Carolyn Buppert, MSN, JD

Disclosures

December 02, 2016

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Question

A nurse practitioner asks, "May my office manager change the Current Procedural Terminology (CPT) code I selected for the evaluation and management visit I conducted?"

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

The answer is straightforward: The rendering provider is the only individual authorized to select and responsible for selecting a CPT code. CPT codes are physician procedure codes, found in Current Procedural Terminology, published by the American Medical Association. The codes dictate the work done for payment purposes.

There is only one scenario in which it would be appropriate for someone to change a CPT code selected by a rendering physician, advanced practice nurse, or physician assistant. That scenario is when a certified professional coder has been engaged to audit documentation and the coder finds that the clinician's documentation doesn't justify the CPT code selected. Even then, the coder should tell the clinician what changes are being made and why. The coder should make sure that the clinician receives appropriate education so that he or she won't make the same mistake again.

Here is a recent case that illustrates the legal implications when someone at a practice changes a clinician's choice of CPT code. The US Department of Justice published this on October 6, 2016, under the headline "Springfield Man Sentenced for Fraud Scheme to Overcharge Medicaid, Medicare at Four Clinics"[1]:

Tammy Dickinson, United States Attorney for the Western District of Missouri, and Missouri Attorney General Chris Koster announced that a Springfield, Mo., man who operated four Family Medical Center clinics in southern Missouri was sentenced in federal court today for health care fraud.

Michael A. Tucker, 47, of Springfield, was sentenced by U.S. District Judge Gary A. Fenner to one year and one day in federal prison. The court also ordered Tucker to pay $54,273 in restitution.

On March 30, 2016, Tucker pleaded guilty to healthcare fraud. Tucker was the owner of four Family Medical Center clinics in Carthage, Mo., Branson, Mo., Nevada, Mo., and Lamar, Mo. In June 2015, Tucker closed his clinics and Family Medical Centers ceased doing business.

Tucker admitted that he defrauded Medicaid and Medicare by submitting claims to the government for more expensive treatment than was provided at his clinics. Although the physicians and nurse practitioners at Tucker's clinics accurately recorded the services they provided, Tucker billed Medicaid and Medicare for more expensive services. The Medicaid scheme lasted from Jan. 1 to June 30, 2014. The Medicare scheme lasted from April 15, 2013, to Sept. 24, 2014.

Specifically, Tucker routinely billed Medicaid for more complex office visits than were actually provided. In addition, Tucker routinely billed both Medicaid and Medicare for the services of physicians when the patient had actually been seen by a nurse practitioner. Lastly, Tucker billed Medicaid for physician office visits when only laboratory services had been provided. In each of these instances Tucker's conduct resulted in his clinics receiving greater reimbursement than they were entitled to from Medicaid and Medicare.

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