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From Health Law Daily, June 18, 2014

CPT averages mean physician could properly bill for 62.83 hours in one day

By Danielle H. Capilla, JD

The revocation of a physician’s Medicare billing privileges was overturned after the physician showed he was able to appropriately bill CMS for an average range of 16 to 62.83 hours of face-to-face time with patients per day. The physician, Dr. Bensimon, showed that the selected Current Procedural Terminology (CPT) codes for time physicians spent face-to-face with the patient or caregiver began with 15 minute increments, but that the codes were expressed in averages and could represent times that may be higher or lower depending on clinical circumstance. The physician went on to show that due to his long hours six days a week, the nature of his practice, his method for seeing new and existing patients, and his large and well-trained staff who took care of screening and preliminary tasks, his billing reflected the time he worked, which was feasible. Therefore, the revocation of his billing privileges was overturned (Bensimon v CMS, Docket No. C-14-254, Decision No. CR3236, May 20, 2014).

Revocation. Dr. Bensimon’s billing was looked at in a probe medical review, which looked at 55 claims for evaluation and management services billed to Medicare for a 24-hour period. The review found Dr. Bensimon billed Medicare for services in his office, skilled nursing facilities (SNFs), nursing facilities (NFs) assisted living facility (ALFs) and in private homes for a total of 1600 minutes, or 24 hours and 20 minutes. Following the review, a Zone Program Integrity Contractor (ZPIC) requested revocation of Dr. Bensimon’s billing privileges for abuse of billing privileges, noting that Dr. Bensimon averaged 16 to 62.83 hours per day, with particularly high billing rates on Sunday. Dr. Bensimon told investigators he was the only supplier who billed Medicare using his number. Dr. Bensimon appealed the revocation. Both parties submitted evidence to the ALJ in lieu of a hearing.

Explanation of billing. Dr. Bensimon informed investigators that he worked 8:30 a.m. to 9 p.m. Sunday through Friday, with an average of 25 appointments per day and 20 walk-ins. He stated that he has a patient base of “thousands” and most are Medicare beneficiaries. Dr. Bensimon sees patients at 13 ALFs, NFs and SNFs, as well as in his office and in private homes. In an affidavit filed with the Departmental Appeals Board, Dr. Bensimon stated that the nature of his geriatric practice means he sees the same patients and problems repeatedly, and he is in close proximity to a number of NFs, ALFs and SNFs, where he sees patient before and after his office hours. With 33 years of experience he stated “he does consultations more quickly than the average time listed in the CPT codes” and he spends approximately 15 minutes with new patients and five with established patients. Because of this he sees approximately 55 patients in his office each day with 80 percent of them being follow-up visits. On Sundays, he works from approximately 7 a.m. to 8:30 p.m. and sees approximately 60 to 70 ALF patients.

Dr. Bensimon reported that his staff handles all preliminary work including reception, vitals, discussion of chief complaints, EKGs and ultrasounds, blood work and urine samples, which limits his time for diagnosis, treatment and counseling. He stated that his staff was well trained, and that when seeing patients in ALFs and SNFs he can see multiple patients in each room, greatly reducing his time there.

Actual hours worked. Dr. Bensimon’s expert testified that on a day that Dr. Bensimon saw 106 patients and the CPT codes indicated he worked 67.42 hours, he only worked 15.83 hours based on 15 minutes per new patient and 5 minutes per existing patient.

Analysis. Under 42 C.F.R. § 424.535(a)(8) CMS has the authority to revoke billing privileges when a provider or supplier “submits a claim or claims for services that could not have been furnished to a specific individual on a date of service.” CMS has the burden of providing evidence sufficient for the basis of the revocation. In this case, CMS’s case was based on multiplying the average times for evaluation and management CPT codes. However, both CMS and Dr. Bensimon provided evidence that the times listed in the CPT codes are averages that can be higher or lower based on the actual circumstances. The CPT codes are not “minimum times required” for billing, but instead “assist the physician in selecting the appropriate level of evaluation and management services for which to bill.” The ALJ found that Dr. Bensimon’s affidavit and that of his expert are credible and unrebutted by CMS, and it was clearly possible for him to see the number of patients he billed for. As a result, the ALJ found no basis for the revocation of billing privileges.

MainStory: TopStory BillingNews CMSNews HomeNews PartBNews MedicareContractorNews PhysicianNews ProviderNews CoPNews SNFNews ZPICNews

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