Pathology Practice Pays $2.4 Million to Settle Whistleblower Suit for Upcoding

Case: 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 government joined the suit, and the provider decided to settle the case. Price tag: $2.4 million, of which the whistleblower will get $456,000; in addition, the practice had to enter into a three-year Corporate Integrity Agreement. Significance: 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.