CMS Unveils Billing, Coding Guidance

CMS and the Medicare Learning Network recently released the Medicare Quarterly Provider Compliance Newsletter; the first in a series of publications intended to offer providers guidance on avoiding common Medicare billing and general errors.

The quarterly newsletter will focus on top issues identified through various sources in each edition, according to CMS. While some of the information presented in the newsletter is an overview of existing guidance, there were a handful of items that providers should note, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and Compliance for HCPro, Inc.

Hoy says that there is some ambiguity when it comes to certain guidance.

Under the recommendations for inpatient hospital services—respirator system diagnosis with ventilator support: principal diagnosis on the claim did not match the principal diagnosis in the medical record.

CMS provides guidance instructing the provider to consult the Benefit Policy Manual, Chapter 15, Section 50.2, on self-administered drugs, which is not applicable to inpatient hospital services, says Hoy.

"It's not clear whether or not they are suggesting that there were a lot of self-administered drugs in the outpatient environment prior to the inpatient admission being billed on the claims in error."

CMS also provides some indistinct education on the issue of unnecessary inpatient services or inpatient services in the wrong setting. 

"In regard to the medical necessity of inpatient pacemaker cases, they indirectly draw attention to condition code 44 by referencing the coinciding transmittal, which suggests that CMS is saying hospitals should be monitoring pacemakers sooner so that they can apply condition code 44 to these cases," she says.

When the newsletter covers the issue of "inpatient hospital services—heart failure and shock (DRG 127) criteria for inpatient care not met," she says. Which is the same issue as the pacemaker cases being not medically necessary—they don't mention condition code 44.  Instead they focus on sections of the Program Integrity Manual related to documentation, Hoy adds.

 "It seems that CMS is looking at these situations differently even though they are both issues of medical necessity of inpatient care because they reference condition code 44 in the pacemaker section, whereas the heart failure and shock section seems to focus on documentation." Hoy says.

Potentially confusing guidance aside, there is certainly something to be learned from this issue, and from future editions. In this initial release, for example, CMS suggests that providers review Chapter 6, section 6.5 of the Program Integrity Manual,where you can find all the standards for medical review, and is something hospitals should definitely review because it has been amended over the last year, according to Hoy.

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