Payers can detect fraudulent billing schemes by analyzing certain CPT codes that are used in conjunction with ICD diagnosis codes and determining aberrant patterns, such as: a provider who bills a certain CPT code with the same diagnosis every time; a provider billing a certain CPT code with a diagnosis that does not support medical necessity; or an illogical number of a certain procedure billed within a time frame. An aberrant pattern, though not always fraudulent, can be investigated and the cause determined. For example, in a recently uncovered fraudulent billing scheme, a medical center in Oklahoma has settled a False Claims Act lawsuit for $1.5 million to resolve allegations it billed for medically unnecessary functional endoscopic sinus surgeries (FESS). The lawsuit involved an otolaryngologist who allegedly performed the FESS procedures on children who did not need them or had not been performed at all.

The FESS procedure is the most commonly-performed surgery for the treatment of conditions of the nasal sinus, including chronic sinusitis. Payers differ in their payment requirements, but generally may consider the surgery medically necessary for the following conditions, among others:

• Suspected tumor
• Suppurative complications
• Chronic polyposis
• Allergic fungal sinusitis
• Mucocele causing chronic sinusitis
• Recurrent sinusitis that aggravates pulmonary disease
• Other sinusitis that is unresponsive to medical therapy

 

The CPT codes used to report surgical nasal/sinus endoscopy are the following, depending upon other structures or associated procedures involved:

31237   
Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement
31254   
Nasal endoscopy, surgical; with ethmoidectomy, partial
31255   
Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)
31256   
Nasal/sinus endoscopy, surgical, with maxillary antrostomy
31267   
Nasal/sinus endoscopy, surgical, with maxillary antrostomy; removal of tissue from maxillary sinus
31288  
Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

Context's Solutions

Payers can identify potential fraud, waste and abuse (FWA) scenarios by utilizing Context 4 Healthcare's industry leading tools, including the FWA Module included in Context's FirstPass™ claim editing solution. The process starts with real-time claims analysis during the adjudication cycle while payers are still calculating claim liability. FirstPass™ contains thousands of rules consisting of millions of editing combinations which are designed to identify potential FWA conditions. Also, the FWA Module provides flexible reporting options for claims analysis.

About Context 4 Healthcare

Headquartered in the Chicago area, Context has more than 25 years of experience in software & data product development. Our solutions impact more than 4,000 clients & tens of millions of lives globally. Context’s solutions have been developed to address the industry challenges currently faced by healthcare payers & providers.

Read Other Context FWA Briefs: Tips for Payers to Improve Monitoring Hospital Admissions for Fraud