by PACC staff
In the healthcare field, fraud and abuse are realities. Fraud is intentional deception to receive reimbursement for services. The Office of Inspector General (OIG) is responsible for handling fraud cases. Some examples are billing for services not provided and altering claims to receive higher reimbursement.
Abuse focuses on not knowing the correct billing and coding rules. However, it does not exempt anyone from penalties. The Correct Coding Initative (CCI) provides guidance and direction on billing procedures. It identifies procedures that are bundled into larger procedures. For example, when a diagnostic colonoscopy is performed with the removal of a lesion using a snare technique. The diagnostic colonoscopy is not billed separately.
According tot he 2021 CPT (R) Professional Manual, "a separate procedure is a component of a larger procedure and this means the diagnostic colonoscopy is bundled into the larger procedure" (removal of a lesion using a snare technique).
To learn more about compliance, fraud and abuse, sign-up for our Compliance Basics webinar.