Source: Fourth Circuit Court of Appeals Ruling, July 2025; Coverage by The Daily Record, Postindustrial, Law360, and Health Law Advisor

In July 2025, the Fourth Circuit Court of Appeals issued a landmark ruling that doctors and clinics can still be found guilty of fraud even when billing codes appear unclear. The case involved Dr. Ron Elfenbein, who was accused of overbilling Medicare by applying high-level Evaluation and Management (E/M) CPT codes for routine COVID-19 testing visits.

The Case

A jury initially found Dr. Elfenbein guilty, but a lower court later overturned the conviction, arguing that the billing rules were too vague. On appeal, the Fourth Circuit reversed that decision, ruling that ambiguity in CPT coding guidelines does not shield providers from liability.

As reported by The Daily Record and Postindustrial, the appellate court emphasized that when multiple interpretations of a code exist, it remains the jury’s role to decide whether a provider knowingly submitted false claims.

Legal & Compliance Analysis

Legal outlets such as Law360 and Health Law Advisor (Epstein Becker & Green) have published detailed breakdowns of the case. Analysts noted that the ruling strengthens the government’s position under the False Claims Act by making clear that providers cannot rely on vague or flexible coding standards as a defense in fraud cases.

The Health Law Advisor blog further explained that juries are entitled to weigh evidence of intent and documentation quality, even in situations where CPT language leaves room for interpretation.

What This Means for Providers

This ruling is a serious warning for healthcare organizations:

Accurate coding and documentation are critical; vague coding language will not protect providers from liability.

Fraud enforcement is tightening, with the DOJ and CMS using more data analytics and audits to detect questionable billing.

Compliance steps should include:

• Regular staff training on coding standards
• Internal audits to detect errors early
• Strong documentation policies to support all claims

Resources such as the official E/M coding guidelines (AMA) and CMS compliance materials should be part of every provider’s compliance toolkit.

Conclusion

According to the Fourth Circuit Court of Appeals ruling and coverage by The Daily Record, Postindustrial, Law360, and Health Law Advisor, this case highlights the growing risks of relying on coding “gray areas.” For providers and billing teams, the message is clear: compliance, training, and documentation are essential to avoiding fraud liability.