Right after obtaining her clinical coding specialist, physician-based (CCS-P) credential, Shirley is hired by a prominent psychiatrist to provide coding and reimbursement assistance for his billing. The policy of this office is to assign codes for a “standard” visit that consists of a 50-minute psychotherapy session unless the physician indicates that a different service has taken place. Shirley begins to notice that as many as 23 patient claims for a single date of service contain the code for a 50-minute psychotherapy session. She also reviews the requirements of the code for “face-to-face” services and observes that the physician indicates this service when only medical record review, medication adjustment, or instructions to nursing staff at the hospital have been performed. The physician has a long-term employee (his wife’s sister), Anne, who prepares and submits all insurance claims. Shirley speaks with Anne regarding her concerns about the 50-minute visits. Anne assures Shirley that there is no need for concern, since no services have been denied by Medicare and since “extra” services are commonly bundled into psychotherapy services in this region. 1. What should Shirley’s role be in this situation? 2. Suppose that an investigation of this practice’s billing irregularities is now underway by the Office of the Inspector General. What steps should Shirley recommend for this practice? 3. How could the threat of a government investigation and a criminal court action have been prevented in the first place? Source: Harman, LB (2001) Ethical Challenges in the Management of Health Information. Gaithersburg, MD: Aspen Publishers, Inc. page 82-83.
