Upcoding remains a perennial target for whistleblowers and government enforcers. Consider the recent case in which 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 provider, probably wisely, decided to settle when the government joined the suit. Price tag: $2.4 million, of which the whistleblower got $456,000; in addition, the practice had to enter into a three-year corporate integrity agreement.
Takeaway: 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.