Pathology Practice Pays $2.4 Million to Settle Whistleblower Suit for Upcoding
Case: A physician brought a whistleblower lawsuit against a New Jersey pathology practice for falsely billing Medicare using CPT code 85390-26, which requires written analysis by a pathologist. The practice’s written records didn’t substantiate use of the higher-paying code and the whistleblower claimed the billed tests actually didn’t require analysis. The government joined the suit, […]

Case: A physician brought a whistleblower lawsuit against a New Jersey pathology practice for falsely billing Medicare using CPT code 85390-26, which requires written analysis by a pathologist. The practice’s written records didn’t substantiate use of the higher-paying code and the whistleblower claimed the billed tests actually didn’t require analysis. The government joined the suit, and the provider decided to settle the case. Price tag: $2.4 million, of which the whistleblower will get $456,000; in addition, the practice had to enter into a three-year Corporate Integrity Agreement. Significance: CPT 85390 is a Hematology and Coagulation Procedures code used with the -26 modifier for billing interpretation and reporting of lab tests to evaluate fibrinolysis and coagulation provided by a physician or nonphysician lab professional. This case serves as a reminder of the importance of having an actual written analysis in your records justifying use of the code to avoid being charged with upcoding.
This content is exclusive to Lab Compliance Advisor subscribers
Start a Free Trial for immediate access to this article and our entire archive of over 20 years of LCA reports.