Ind. Settlement Announced in Spinal Manipulation Billing Case

Sarasota, FL (WorkersCompensation.com) – Physicians are already spending around 45 percent of their time on administrative duties. While those duties may reduce their time seeing patients, a recent settlement announcement by the Attorney General in Indiana highlights yet another example of why accuracy in coding and documentation is critical. 

According to a study in May of last year, the most common causes for coding errors by physicians was lack of formal coding education, inadequate clinic documentation, and the lack of systems to catch errors and provide feedback. Talk to any medical practice manager, and they will tell you the top two struggles when it comes to their physicians is accurate coding and documentation. 

In a news release earlier this month, Indiana Attorney General Todd Rokita announced a $700,000 settlement for alleged overbilling by Southeastern Medical Center (SEMC), located in Hammond and operated by orthopedic physician Kishan Chand, MD. Chand, age 86, is an Orthopedic Surgeon that graduated from King Georges Medical School in India in 1959. SEMC provided typical orthopedic services to patients, including pain management, exams, and surgeries. 

Investigators from Rokita’s Medicaid Fraud Control Unit assert that they uncovered abnormalities in Medicaid claims billed by SEMC. According to the settlement documents, SEMC billed Medicaid for spinal manipulations services that were alleged to have been provided by its practitioners. 

From January 2016 through June 1, 2021, investigators contend that SEMC billed approximately 13,101 claims with spinal manipulation code 22505. Procedure code 22505 is when a provider manipulates the spine while the patient is under general anesthesia, and no incision is made. 

According to Spine-Health, the procedure is non-invasive, and is commonly used in patients that have chronic pain and cannot tolerate stretching. Under anesthesia, stretching and breaking up of scar tissue or adhesions can be tolerated in an effort to improve range of motion and improve pain. The manipulation can be performed with general anesthesia where the patient is unconscious, mild sedation where the patient is awake but not feeling pain, or under local anesthetic which is injected directly into the joint. In addition to pain management, spinal manipulation may be used as an option to avoid surgery in some cases. 

According to the settlement agreement, SEMC agrees that claims billed with code 22505 were not performed under general anesthesia, but contend that they were not false claims. However, investigators allege that the documentation did not support spinal manipulation services. 

In an effort to avoid further litigation, SEMC agreed to pay out $465,419.52 in restitution, and $234,580.48 in additional recoveries for a total of $700,000 in settlement. From 2016 to 2021, the average physician Medicare reimbursement rate in Indiana for code 22505 was $123.46, with CMS paying between $121.51 in 2021 and $125.74 in 2017. If payment was at 100% without any multiple procedure reductions, total reimbursement based on the average fee would be $1,619,807.64. In that case, the settlement would equate to $919,807.64 in savings for the provider based on reimbursement alone. The settlement is not an admission of guilt and resolves SEMC of the claims allegations. 

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