CMS has initiated the second volume of its Medicare Quarterly Compliance Newsletters, one year after the launching the inaugural edition of the publication. The newsletters are designed to offer providers guidance on avoiding common Medicare billing and general errors.
These educational newsletters are designed to help providers understand the major findings identified by Medicare administrative contractors (MACs), recovery auditors, program safeguard contractors (PSCs), zone program integrity contractors (ZPICs), and other governmental organizations, such as the Office of Inspector General. They aim to help providers, suppliers, and their staffs understand claims submission problems and how to avoid certain billing errors and other improper activities at their facilities.
CMS identifies recovery audit findings and offers guidance for the following issues: (Provider types affected in parentheses):
- Incorrect facility vs. non-facility reimbursement (Physicians who bill for services provided to a Medicare beneficiary in a facility setting)
- Unbundling of skilled nursing facility (SNF) services subject to consolidated billing (CB) (Physicians)
- Wheelchair unbundling (Durable medical equipment suppliers)
- Improper billing of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) during a Part A inpatient stay (DMEPOS suppliers)
- Improper billing of clinical social work (CSW) services during an inpatient hospital stay (CSWs providing services to Medicare beneficiaries in a covered Part A Inpatient Hospital stay)
- Validation of MS-DRGs with ventilator support of 96 or more hours (Inpatient hospitals)
- Improper coding of MS-DRG 853, infectious and parasitic diseases with operating room (OR) procedure and major complication or comorbidity (MCC) (Inpatient hospitals)
- Improper coding of coronary bypass with percutaneous transluminal coronary angioplasty (PTCA) with major complications and comorbidities (MCCs) MS-DRGs 231, 233, 235 (Inpatient hospitals)
- Improper coding of seizures MS-DRGs 100, 101 (Inpatient hospitals)
- Improper coding of nervous system disorders (Inpatient hospitals)
- Improper coding of lymphoma and non-acute leukemia with major complications/comorbidities (MCC) MS-DRG 840 (Inpatient hospital)
It's clear that providers must be more cognizant of the rules as they relate to different services provided within the hospital, according to Elizabeth Lamkin, MHA, partner,PACE Healthcare Consulting, LLC.
"For instance," she continued, " if a physician performs a procedure in the hospital setting, the Part B physician will be reimbursed at a lower rate because the physician is using hospital resources, and typically the hospital (Part A) will charge a facility fee."
In addition, Lamkin suggests that billing errors such as the highlighted issues above will now be easier to notice, which will help to recognize further problematic billing errors for providers.
"These billing errors are going to be much easier to identify with all providers under MAC regions because the MACs can view an episode of care across Medicare parts A, B, C, and D," she says. "The dates and services provided must match the rules, and providers should be collaborating to be compliant with all billing procedures or face being vulnerable to a RA (recovery auditor) takeback or denial."
When challenging billing issues such as these are identified for providers, it serves as a valuable source of information, says Donna Wilson RHIA, CCS, CCDS, senior director at Compliance Concepts, Inc., in Wexford, PA.
"What a great resource for providers regarding the major findings of RAC auditors throughout the nation," she says. "Oftentimes, CMS guidance can be confusing to providers, but having these simple patient examples will hopefully assist providers in some unanswered questions."