tci Medicare Compliance & Reimbursement - 2019 Issue 1

Compliance: Modifier 59 Abuses Lead to $12.5 Million Settlement

Improper unbundling lands healthcare organization in hot water. Now, that you’ve aced all the latest ICD-10 and CPT® updates, your work is done — right? Wrong. One recent false claims case suggests that being lax about how you report modifier 59 (Distinct procedural service) claims could spell disaster for your practice. Context: Last month, the Department of Justice (DOJ) settled with founder and owner Emil DiIorio, MD and his Philadelphia-based organization, Coordinated Health Holding Company, LLC (Coordinated Health), for false orthopedic surgery claims submitted to Medicare and other federal programs under the False Claims Act (FCA), suggests a...

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