Medicare Audit

Hi all
I received this letter from a doctor. Comments and advice appreciated
Hi Ian
Had feedback from Medicare today as a result of the audit they did and despite good notes and pathology to prove 30195/30202/30203 they want me to pay back $486.35.
They stated some of the pathology is too old to call the lesions in the same area cancers. They couldn’t tell me how old is acceptable and a time scale is not stated in the MBS.
I’m not sure if anyone else has been audited with regard to this but it looks like the start of what they promised with regard to auditing skin cancer billings.
I was billing as taught by …. so now I’m uncertain what is beyond the realms of acceptable. I have a hotline number to phone to ask the question and I will update you in due course.
  1. #1 by Peter Bourne on February 10, 2011 - 8:59 pm

    My very strong suggestion would be to say that you did you thought that you were billing correctly and then pay back the $486.35 immediately.

  2. #2 by Dr Ian Katz on February 10, 2011 - 9:06 pm

    Peter – is that because you think $400 is a small price to pay to have Medicare off your back and unlikely to audit you again for a while…

  3. #3 by hein vandenbergh on February 10, 2011 - 9:22 pm

    Yeah, cancers do that – one day malignant, next day benign 🙂

    Seriously, but — legally, if there is no timescale specified they cannot use that to invalidate a claim. A govt officer acts under delegated legislation, and if it ain’t in the rules, regulations etc [as the Medicare Schedule is], they cannot use such measures. The Admin Appeals Tribunal would laugh Medicare out of Court. Of course, for $ 400 they KNOW you’re not going to go to the Admin Appeals Trib, but one day………

  4. #4 by Stewart Precians on February 10, 2011 - 11:07 pm

    Would be interested to know how extensive was the audit, $486 minimal and with the amount of billing done there must be some clerical errors so could expect to make some payment or Medicare to pay the doctor.

  5. #5 by john pyne on February 10, 2011 - 11:27 pm

    Sounds like a judgement made by a non doctor about a subject they know very little about.

    This is a bully tactic.

    If we had a single College with substantial funds and legal clout, we would be in a better position to deal with this sort of action.

  6. #6 by Jim Wall on February 10, 2011 - 11:53 pm

    This is another stupid bureacratic recipe for worsening patient care and increasing costs. Now we will biopsy new lesions which we know are the same as the previous ones at $42 a time, and then have to treat them under 30202/30203 anyway. Two appointments, a biopsy and cryo for the patient instead of one appointment and cryo. I work in a regional area and many patients travel an hour each way to see me. So add the fuel costs, enviro impact and time. Plus I’m booked up many weeks ahead, so I can do without unnecessary procedures and repeat appointments.

    What problem are they finding with the 30195? As long as it’s not for “viral verrucae (common warts) seborrheic keratoses, cysts and skin tags” there doesn’t seem to be a problem. And there is no requirement for histo. Are they simply suggesting that the doctor is statistically doing too many? Presumably then these lesions will be formally excised, with the consequent increase Medicare rebate PLUS histo.

    It would have cost them vastly more than the $486 to undertake the review, visit the doctor and do all the reporting!

  7. #7 by Farid Nassif on February 11, 2011 - 12:55 am

    My understanding of 30202 is that the previously proven cancer should be close in time and place (anatomical location) even though it’s not specified how close.
    On a lighter note, I suggest we all make an agreement with medicare to pay them yearly $400 each and they get off our backs. They’ll save on the audit costs and probably collect more money that way..

  8. #8 by hein vandenbergh on February 11, 2011 - 1:58 am

    NEVER EVER offer a bureaucrat money!

  9. #9 by DT on February 11, 2011 - 3:11 am

    medicare should crack down real hard on skin cancer item numbers ! certain numbers are way over used or rather abused ! e.g 30195, double dipping-even when privately billed e.g charging for removal of sutures, charging consult ontop of excision item numbers. Nerve block item number is another rout….. what’s with charging facial nerve block when excising a cheek bcc with local infiltrating add in ?.

    30195 – is not just flicking off a tiny keratin mass then freezing the base… 30195 -takes atleast 3mins for an expert who has been doing this for 30 yrs !!!! and hardly ever done at all. Get the freeze gun and learn to use it properly !!

  10. #10 by hein vandenbergh on February 11, 2011 - 6:23 am

    You make a good point, Dai. The issue here however is NOT what drs do wrong, but what they do right and then are accused by Medicare of what amounts to fraud [a crime], on a basis which is non-existent in law. Medicare in these circumstances acts ultra vires the legislation, and that should not happen – and will not stand-up if challenged in court or the AAT. Not only that, they intimidate doctors, and that amounts to acting in bad faith, something else the AAT has serious issues with. Challenge the time-serving bastards.

  11. #11 by Padmundo the Magnificent on February 11, 2011 - 6:50 am

    @DT You need to get over yourself.
    BENIGN NEOPLASM OF SKIN, other than viral verrucae (common warts) seborrheic keratoses, cysts and skin tags, treatment by electrosurgical destruction, simple curettage or shave excision, or laser photocoagulation

    Cut off lesion in 2 directions, diathermy base. Done. I have learnt to use the “freeze gun” and my first step is not to pick it up for a 30195.

  12. #12 by Dr Ian Katz on February 11, 2011 - 6:56 am

    Actually, the original comment about 30195 was a mistake – the doctor meant she was being audited for 30196.

    But the comments for 30195 are still relevant.

  13. #13 by AMI on February 11, 2011 - 7:11 am

    30195 is a very good number but for those I know who use it , i think they should go and work for A.M.I and Bill Longer !!!!!! Don’t ruin it for others

  14. #14 by Jim Wall on February 11, 2011 - 11:00 am

    I think the Moderator should eliminate any comments where multiple exclamation marks are used. DT and AMI are either the same person or twins.

    We are trying to have a reasoned discussion here.

    And for DT, I have been doing 30195’s and their pre-Medicare and pre-Medibank antecedents for more than 35 years, so don’t try to pull rank on me.

    Irritable commentators add nothing and are simply an irritant.

    None of the skin cancer doctors I work with or know do anything outside the Medicare definitions. It is the PSR that tries to reframe the definitions to its own ends, not us.

  15. #15 by Dr Ian Katz on February 11, 2011 - 12:16 pm

    Latest update from the audited doctor:

    Ok. I had a long chat with Medicare MBS advice line this afternoon and this is the summary.

    A 30202/30203 has no time limit stated in the MBS but that is because there is no time limit FULL STOP. One lesion per anatomical area needs to be biopsied for confirmation first (if a GP consult, obviously a specialist can use his opinion) and then treated with cryo at a subsequent appointment, along with the other lesions in the same area. Thereafter, I was told that the next consultation and skin check was as if I had never seen the patient before without a history ie starting from scratch. So much for continuity of care.

    The support officer I dealt with eluded to the fact that she had spoken at great length to the ‘Billing Experts’ and that she was told to tell me this. She also said she would be angry with the information she was told to give me as she couldn’t see how the MBS definition could be interpreted this way! I hope her call wasn’t being recorded.

    Medicare need to get real about this, many doctors appear to have misinterpreted the MBS. I’ve been given the Medicare email address to put this issue in writing and request the MBS is re-worded appropriately, which I shall do. I’m unsure whether to discuss it with MIPS or whether to just suck up the payment but I would be interested to know how many others are using these numbers. I don’t need to make a decision until I get the invoice – a while yet.

  16. #16 by Dr Ian Katz on February 11, 2011 - 12:17 pm

    I agree with Jim. Please sign your name to any posts.

    • #17 by Andrew Montanari on February 12, 2011 - 5:06 am

      Re 30202/30203 has no time limit…

      This is what is taught by A/Prof Anthony Dixon, ex Medicare Advisor :
      Once malignancy is proven (by histo) in an anatomical area, then items 30202/30203/30196 continue to apply without time limit. He says this stands to reason, becasue if an anatomical area develops a cancer, then that area is prone to developing more in the future.

      This interpretation is widely used by our peers, yet I know of someone who was asked to pay back substiantial $$ for these items, when the original histo was over 6 months old.

      This time limit is nowhere in the Medicare Benefits Schedule, which says :
      “… Items 30196 to 30203 (inclusive), the requirement for histopathological proof of malignancy is satisfied where multiple lesions are to be removed from the one anatomical region if a single lesion from that region is histologically tested and proven for malignancy.”

      The whole thing boils down to no standard interpretation of MBS codes.
      When someone tries to ask, Medicare rarely come up with an answer.
      They just leave us to ‘sweat’.

      Only when the definitions made clear, will these issues be solved.

      Has anyone written to Nicola Roxon?

  17. #18 by DT on February 11, 2011 - 10:36 pm

    I in complete agreement with AMI and Medicare police.
    30195 eluded to above is very lucrative. It takes only a few seconds to do for some practitioners : “Cut off lesion in 2 directions, diathermy base. Done. ” and yet medicare rebate is $51.92. The rebate for 30071 is $42.75 and takes much longer to do.
    Insiders have said that the purpose of 30195 is to rebate those necessary procedures such as the the removal of pyogenic granulomas, problematic large moles, disfiguring syringomas etc…

    the practitioners who are using these item numbers e.g 30195 must bear in mind the consequences of incorrect use. Medicare will severely restrict those items sooner or latter as they have done with sclerotherapy safety net abusers and cosmetic practitioners claiming 30195 for snipping skin tags.

    practice well, be respected and think of your fellow colleagues

  18. #19 by hein vandenbergh on February 12, 2011 - 6:13 am

    Yes, ‘anonymous’ comments are not allowed – which is how initials or a pseudonym rate in my book. Not that we all don’t know that DT is Dai, and don’t we love him for his provocative insights – although in this case his comment was off the point.

    As to ‘pulling rank’, I guess the written word can come over rather harsh, and doesn’t show the twinkle of the eye or the grimace of frustration when the comment was made. I’m sure no-one here is trying to pull rank despite superficial impressions – we’re all in the same boat, so let’s pull in the same direction and GET somewhere. Whatever rank may signify, let’s fageddud. Almost 40 years after graduating, both Medicare and others in the profession who do not know me still rank me on the bottom rung. I know better, and care not one whit.

  19. #20 by Jim Wall on February 12, 2011 - 6:53 am

    Apologies to DT. It’s just that old feeling of being attacked from every side that we all know so well. I didn’t realise there might be a twinkle in his eye.

  20. #21 by hein vandenbergh on February 12, 2011 - 10:52 am

    Thanks, Jim. When Dai’s eyes do not twinkle, he’s dead! This, however, is what Medicare sets-out to do: divide honest and like-minded souls, and conquer. A prerequisite to working for Medicare is an examination on the finer points in Macchiavelli’s ‘The Prince’: divide et conquere. Set, of course, in Florence, which at the time was a fairly insignificant provincial town [even though officially a City State], in a sense the Canberra of Romagna – Rome, Napoli, and Venice being the real seats of power on that ancient peninsula.

    Agghhh, if only a bit of culture existed in that Medicare joint, DECENT docs might even join-up to truly educate rather than mete out arbitrary punishments for sins not committed. Of course, they do NOT go out and audit, let alone punish, dermatologists, as the latter would not allow themselves to be pushed around, but do some reverse intimidating, and call their college [no ‘C’] afterwards to ensure their influence-peddlers in Canberra would be knocking on Miss Rocks-on’s door the next morning. Have a look next time: low-brow, very low-brow.

    We need an effective College of Skin Cancer Practitioners very soon, or else procedural work will be paid on an attendance-basis before we know it. There’s a lot of grandiose talk, a lot of revenue-raising by organising the same old same old [conference], but NOTHING goes towards effective representation of our interests.

    I spent a 3 years involved in the politics of it all until about 2 yrs ago and believe you me: democarcy, even if seen as mob-rule, is not one of our current organisation’s strengths: a few people call the shots, without taking notice of informed commentary by its membership………… non populo sed ego. The rest was sold to UQ: the Money-changers in the Temple.

  21. #22 by hein vandenbergh on February 12, 2011 - 11:00 am

    Ah, now I understand some, ‘A/Prof’ Dixon “ex-Medicare advisor”……. I’m permanently in his spam-bin. Good. However, ‘proneness’ is not a legal concept, except in sentencing terms. Definitial loose-ness has no place in this, and being prone is about as loose as one can get, unless on the run from the law.

  22. #23 by Peter Bourne on February 13, 2011 - 1:07 am

    From what I have been told, “ex-Medicare adviser” is not a completely accurate description of Anthony D. He was one of many on the AMA Skin Group panel which subsequently advised Medicare on skin item numbers. Sometimes Medicare heeded the advice, often they didn’t. I understand he left this committee…the story of exactly how this happened will vary depending upon who is asked!

    My opening comments about paying up and shutting up still stand. Facing off with Medicare by oneself is not recommended. A lobby group from SCCANZ and/or ACSCM would have more success is clarifying these issue I think. The sooner the 2 groups join forces the better…for this and other reasons.

  23. #24 by hein vandenbergh on February 13, 2011 - 1:51 am

    Peter – why do we need to join forces with AD or anyone else? Going by the chest-beating, I thought that we – SCCANZ – now stood head and shoulders above any other group, yet we do not seem to represent our members’ interests in Canberra at all. There is NO advocacy, just ineffectual moaning on blogs. Hence my earlier, maybe fairly acidic, comments. These are not to be taken personally, I know the reasons behind it – but that does not change the facts.

    Maybe if all members could be asked to report the details of their transgressions as alleged by M/care [anonymously if preferred] to SCCANZ, and someone like myself could look at the legalities of each Medicare action, a file could be built-up with which we could inflict some serious damage on Medicare: there are plenty of lawyers who’d LOVE to start a class-action in a matter such as this. Even without that, notice will be taken of evidence of systematic intimidation of individuals by a Govt agency. Two basic legal breaches appear to recur again and again: M/care arbitrariness and M/care acting ultra vires the legislation. Both very simple and easy-to-prove administrative law core-concepts.

    I promise to keep my fees modest 🙂

  24. #25 by Peter Bourne on February 13, 2011 - 7:21 am

    Good ideas, Hein! It seems to me, though, that a lobby group representing ALL primary care docs, may have more impact than just one sector, albeit the largest.

  25. #26 by hein vandenbergh on February 13, 2011 - 9:29 am

    Peter, that lobby-group is the RACGP, and you know my (VERY well-founded) opinion about them. Not only that, they receive a lot of their funding from the Fed Govt, and are its handmaiden. I cannot see that we – with limited resources – should go in to bat for the majority of GPs, a lot of whom are part-time femmes who contribute little beyond their working hours, or GPs who make morally questionable but strictly speaking legal fortunes by ‘doing care plans’. Yes, I know, I exaggerate, but you get my drift.
    We must speak-up ONLY for ourselves, in a well-organised manner, as we do a very special job, which can only be done well and cost-effectively for the taxpayer by our personal significant $$$ investment in training over a number of years. Time for skin cancer action pure and simple. The only question we have to ask is: “Is SCCANZ up for it?”. If it thinks it is, what about an announcement in our next newsletter 🙂 requesting input such as I suggested earlier, with the option of it being de-identified. It worked in the aviation industry. If SCCANZ cannot organise this – about a very serious issue affecting our very existence and the value of our own time and money investment – it really has little reason to continue to exist. Sure, to provide training, at significant cost – and then M/care comes in and says “Ye shall all bill on an attendance basis only (except FACDs)”.
    Most colleges worth their salt mix the academic with the political, an unavoidable compromise in the post-Thatcherite era. We shouldn’t be too precious about it ourselves.

  26. #27 by Stewart Precians on February 13, 2011 - 10:16 am

    Andrew Montanari, can you pleases confirm that what you are saying about 30196 is that once histopathology has shown a malignancy, say a superficial BCC on the upper back, if at later dates no matter how long after, the doctor diagnoses new superficial BCC’s on the upper back, histopathological confirmation is not necessary to claim 30196.

    On the matter of curette and cautery as a treatment option, may I encourage those skin cancer doctors who do not use this method to do so, as it is a quick and easy process both for patient and doctor for less dangerous and smaller NMSC’s, and sometimes larger ones, and the cost is small to both patients and Medicare. It can usually be done at the time of consultation and so the patient does not have to return for another visit, nor return for ros. If my interpretation of what A.Dixon told Andrew is correct, billing will not not even have to be held for histo. confirmation in a lot of cases.

    Further to this, I would be interested to hear what others do re billing in regard to the histo. confirmation reuirement.

    • #28 by Andrew Montanari on February 24, 2011 - 7:05 am

      Reply to Stewart #26:
      Yes, Anthony Dixon did say it:
      eg superfic BCC proven years ago on the upper back, then 30196 and 30202 can apply without new histo. This was in his Medicare Interpretation lecture from one of his 2 day courses.

      BUT – Dixon is not Tony Webber and
      Medicare now seems to say there is a time limit:

      I no longer follow Dixon’s advice after the incident where my colleague paid back all 30196/30202 when histo was over 6 months old.

      I think were have our hands tied and I would agree with Dr Katz #15.

      These days I might biopsy one day and later, with histo report in hand, treat a few lesions accordingly all at once. For patient comfort, if all lesions are initially documented, I might treat them separately over a short period.

  27. #29 by hein vandenbergh on February 13, 2011 - 10:37 am

    Stewart, that would be hard to defend. ‘Histo proven’ will need to be repeated if dealing with a different lesion, even in the same general region, PARTICULARLY after a decent time-interval. That whole ‘proneness’ business of Dixon’s is rubbish. Skin which has had a BCC on it is also prone to develop a melanoma, and other item nos. apply there, unless you’re a cowboy. If an earlier SCC, how confident can you be that you are dealing with another one rather than a mere AK?

    30196 is indeed a good Rx modality, esp in those old turks who have lots of skin lesions. However, I always play it safe and get histo, and THEN bill. I’ve never done one without histo yet, and sometimes one is indeed wrong. But if I bill for a malignancy I plurry well make sure the histo is there to prove it, come M/care ‘advisor’ time. It is not hard to be one step ahead of ’em, you know. Maybe I am fortunate in that my patient base is pretty well known to me. If they are not scheduled to come back for anything in the near future [although I try and find a way to do so] we send them an account, or if they are DVA we ask them to come in and make with that electronic billing gadget [Tyro??] which was foisted on us, 16 cts/billing, and then nothing – but that was yet another con-trick by the gummint.

  28. #30 by Jim Wall on February 16, 2011 - 11:51 am

    I agree with Stewart (who I have not seen for 30 years) re usefulness of 30196, especially for older patients who will not tolerate formal excision well and where intercurrent illness presents a greater problem. Get the cancer off and even if you get a recurrence you can do a repeat curettage 6 months later with minimal fuss. But I think you need histo proof of diagnosis.

    I am wondering why there is such a reticence to even speak about taking on Medicare/PSR? Have those who advise surrender been hit? Is there other information or speculation that we should know? Are we so concerned that we are being watched that we can’t speak freely?

    The AAT would wallop the PRS on their 30202 interpretation, so why all the shyness?

  29. #31 by hein vandenbergh on February 17, 2011 - 7:35 am

    Jim – Medicare relies on a doctor NOT ‘taking them on’, as that will lead to publicity. As you well know, our press is sensasionalist, and it can ruin or seriously damage your reputation both with professional colleagues and the public, especially in smaller communities. Even in the big smoke, every area has a ‘regional rag’, mainly advertising tradies and prostitution. However, they need at least one sensational headline on p. 1. There are only so many ‘glassings’ in Manly in a week, so that’s a bit of a dead end. Imagine: your friendly local GP or skin ca doctor being hounded by Medicare – on behalf of the honest, hard-working, taxpayers – for FRAUD. It’ll raise excitement for weeks.

    That is why I suggested that a doctor who is NOT the subject of any investigation collects data, de-identified, if things happen to colleagues, and hit M/care with that. In which case they would not dare to target the dr with the dossier, especially if that dr knows they have nothing on him.

    Bring it on!

  30. #32 by DiTran on February 28, 2011 - 4:00 pm

    30203 – ? what’s that ? this is how I do it -> pick a BCC, draw a circle, then draw another circle around that circle say 2-3 mm bigger. FREEZE an ice ball. squeze it. then freeze again for total of 30sec. THEN let thaw – about 2mins- then FREEZE again. SO if you have 10 bccs ( which i have rarely seen. ). you time spent with the patient will be 30secs*10 lesions* 2 freeze thaw cycle = 10mins + time checking, undressing, de-undressing = 30mins. FOR SCC freeze time is even longer!

    • #33 by Dr Ian Katz on February 28, 2011 - 8:49 pm

      I think you are wrong Dai – you only need a freeze ball for 20 sec which takes about 6-8 sec of cryo, then a thaw and repeat and you can do all the others at the same time and then start from the beginning again so that it is much quicker than you say

  31. #34 by Liza on March 13, 2013 - 10:35 pm

    Great article. I am dealing with many of these issues as well.

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