Opinion ID: 2263396
Heading Depth: 3
Heading Rank: 2

Heading: Billing Fraud.

Text: The trial court determined that a reasonable jury could not find by clear and convincing evidence that Dr. Stark's conduct constituted billing fraud by charging Ms. Caulfield's insurance carrier $70 for an office visit under Current Procedural Terminology (CPT) Code 99213 and submitting a diagnosis of diarrhea. The Caulfields contend that in order for Dr. Stark to bill Ms. Caulfield under CPT Code 99213, he would have had to satisfy two of the three components listed in the American Medical Association's 1995 Evaluation and Management Services Guidelines (the Guidelines). [6] Dr. Stark testified that he had believed he was justified in using that particular CPT code because he had made a medical decision to perform a colonoscopy on Ms. Caulfield and he had spent approximately thirty minutes with her discussing that procedure. With regard to his diagnosis of diarrhea, Dr. Stark testified that Ms. Caulfield complained of alternating bowel movements, of which diarrhea was a symptom. Dr. Stark further testified that the space on the billing form was not large enough to accommodate multiple diagnoses and that he did not believe that submitting a diagnosis of diarrhea constituted billing fraud. There is no additional evidence to substantiate that Dr. Stark's actions amounted to billing fraud. It is not disputed that Dr. Stark had a face-to-face consultation with Ms. Caulfield on May 17, 1995 for which he billed her $70. Dr. Stark also had a telephone conversation with Ms. Caulfield on March 17, 1995 of an unknown duration in which they discussed Ms. Caulfield's family history of colon cancer. He apparently did not submit an additional bill for this earlier service. The Caulfields did not demonstrate what the correct billing code for this level of service should have been or suggest that if a more appropriate billing code had been used the charge for the services would have been less than $70. Furthermore, there is no evidence that Dr. Stark was compelled to submit a diagnosis of diarrhea or otherwise be denied payment for his services. Thus, Dr. Stark's actions with respect to the billing form can be characterized, at most, as negligent preparation or ignorance of how to properly complete a billing form in conformity with the Guidelines. See New York Title, supra . In sum, the Caulfields cannot sustain their claims of fraudulent misrepresentation.