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The page below is a sample from the LabCE course Medicare Compliance for Clinical Laboratories. Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

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Case Study 9

A billing clerk is processing requisitions as a part of the normal day's work. The department is under pressure to reduce accounts receivable, which means that the more clean claims that are filed, the better. This particular requisition is for a Medicare patient who had an "LMRP" test. Unfortunately, there is no diagnosis code associated with the ordered test. The billing clerk remembers an earlier requisition that she processed from the same doctor that had this same test ordered but with a diagnosis code that allowed the test to be billed. She locates the previous requisition, notes the code that was used, and adds it to the current requisition. This will help her meet the department goal of getting claims paid and reducing accounts receivable. Is this acceptable practice?
Correct Answer: No, this is not acceptable practice, even though the same test is ordered by the same doctor for both patients.
Discussion: A laboratory employee should never change, add or use previously received diagnosis information for the purpose of making a test billable to Medicare, or for any other insurance or payer. This is a form of fraud and for each claim submitted as a result of this activity, the laboratory is liable for a false claim and would have to pay the government back up to three times the reimbursement for the test and up to $10,000 for each claim submitted.