OIG Notifying Providers of Incorrect Billing Practices

The Office of Inspector General (“OIG”) has been sending notices to providers recently, suggesting that the providers have been billing incorrectly, leading to overpayments from Medicare. The alleged issue stems from the billing of extremity venous studies. When performing these studies, providers will often bill under HCPCS Codes 93970 or 93971 and 93965 for the same patient on the same date of service.

The reporting requirements are unclear, and there are no bundling edits to stop practices from reporting both services for the same patient on the same day. Nevertheless, the OIG has been notifying providers that they are looking into the billing of both codes on the same dates of service, implicating that providers have been billing fraudulently.

The 2016 CPT Code Book describes the codes as the following:

• 93965 – Noninvasive physiologic studies of extremity veins, complete bilateral study (g. Doppler wave form analysis with response to compression and other maneuvers, phleborheoqraphy, impedance plethysmography)
• 93970 – Duplex scan of extremity veins including response to compression and other maneuvers, complete bilateral study
• 93971 – Duplex scan of extremity veins including response to compression and other maneuvers, unilateral or limited study

In the notices being sent out, the OIG is telling providers how they believe the three CPT codes should be billed; the CPT book definitions and rules are as follows:

• Duplex scan: describes an ultrasonic scanning procedure for characterizing the pattern and direction of blood flow in arteries or veins with the production of real-time images integrating B-mode two dimensional vascular structures, Doppler spectral analysis, and color flow Doppler imaging.
• Physiologic studies – Noninvasive physiologic studies are performed using equipment separate and distinct from ultrasound imager. Codes 93922, 93923, 93924, and 96965 describe evaluation of non-imaging physiologic recording of pressures with Doppler analysis of bi-directional blood flow, plethysmography and/or oxygen tension measurements appropriate for the anatomic area studied.

The OIG states that the technologies and equipment used to perform the procedures described in Code 93965 are outdated and completely separate technologies compared to those used to perform Codes 93970 or 93971. The OIG maintains that there rarely would be medical necessity for both technologies to have been used and both procedures to have been performed on the same date of service.

The OIG is asking providers to prove that they owned the equipment necessary to perform the procedures under Code 93965, and that the claims for such code were properly submitted to Federal Healthcare programs. Providers should review their current billing practices and compliance policies to ensure such practices and policies are in accordance Medicare requirements.

For over 30 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, including compliance and the defense of Medicare overpayments. If you have received a letter from the OIG with these overpayment implications, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.