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Regulatory MonitoringArchive for November, 2008
- The hospital bill for laboratory services only after they are performed
- The hospital bill only for medically necessary services
- The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
- The CPT or HCPCS code used by the billing staff accurately describe the service ordered
- The coding staff only submit diagnostic information obtained from qualified personnel
- The coding staff contact the appropriate personnel to obtain diagnostic information when the individual who ordered the test has failed to provide such information
- The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
- The hospital conduct routine audits to assess billing compliance with the regulations
Tip: Understand the difference between a Medicare appeal and a Medicare reopening
By Deborah K. Hale, CCS
When facing a denied claim, organizations have two options if they believe the denial is wrong: file an appeal or ask for a reopening. A reopening can be used instead of an appeal if there is a minor clerical error on the claim. The basis of a reopening is to correct the minor clerical error or omission that resulted in the initial claim denial. If there were no clerical errors, and you disagree with a Medicare decision or policy, then an appeal must be made.
If you are unsure whether the issue on your claim is based on a minor error, it’s best to file initially for a reopening. You have the right to file for an appeal if your reopening request is denied. Do not file for both a reopening and an appeal at the same time; doing so will cause your request for a reopening to be considered null and void.
Valid reopening errors include:
- Mathematical or computational mistakes
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer error
- Denial of claims as duplicates, which the party believes were incorrectly identified as a duplicate
- Incorrect data items, such as provider number, use of a modifier, or date of service
By Hugh E. Aaron, MHA, JD, CPC, CPC-H
By now, many of you may have started to look over the display copy of the 2009 OPPS final rule. Personally, I find the display copy somewhat hard to use because of the way it is formatted (i.e., triple line spacing, etc.). At 1,827 pages, printing the display copy produces a huge volume of paper, even when printed double sided.
The good news is that the “official” Federal Register copy is scheduled for publication in today’s (November 18) Federal Register. To access today’s Federal Register, visit www.gpoaccess.gov/fr/index.html and click on one of the links embedded in “Browse the Table of Contents from today’s issue in HTML or PDF formats.” The official copy should be less than half the size of the display copy due to differences in formatting between the two versions.
A good way to tackle the final rule is to start by browsing the table of contents to get a feel for the big picture. After reviewing the table of contents, I usually read the new and revised regulations, which appear at the end of the “preamble.” The preamble is CMS’ detailed discussion of the rule, including CMS’ response to comments on the proposed rule submitted by the public. To quickly access the regulations section of the final rule, search for the text “List of Subjects.” After I’ve reviewed the new and revised regulations, I then go back and read the preamble (or at least the sections of the preamble that are relevant to my work). Although the preamble is merely interpretative guidance (rather than law), it typically provides a treasure trove of important details relating to hospital compliance and revenue cycle management.
CMS adds certain entities as originating sites for payment of telehealth services under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
On November 14, CMS issued two transmittals adding certain entities as originating sites for payment of telehealth services, pursuant to Section 149 of MIPPA. Eligible originating sites will also include hospital-based or critical access hospital-based renal dialysis facilities (including satellites), skilled nursing facilities, and community mental health centers.
Effective date: January 1, 2009
Implementation date: January 5, 2009
View the first transmittal.
View the second transmittal.
CMS updates the initial preventive physical examination (IPPE) benefit
On October 31, CMS re-communicated an October 17 transmittal expanding the IPPE benefit under Medicare Part B.
Effective date: January 1, 2009
Implementation date: January 5, 2009 (unless otherwise specified by the individual business requirement)
View the transmittal.
View a related MLN Matters article.
CMS releases MLN Matters articles
CMS released two MLN Matters articles last week related to transmittals previously announced in Medicare Weekly Update.
- Update to Medicare Deductible, Coinsurance and Premium Rates for 2009
- Compendia as Authoritative Sources for Use in the Determination of a "Medically Accepted Indication" of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen
CMS also released a special edition MLN Matters article last week.
As with the prior ABNs, the revised ABN is designed for use by hospitals, physicians, and certain other furnishers of healthcare services (“healthcare providers”) to notify Medicare beneficiaries when outpatient services are expected to be denied, primarily in the following circumstances:
- The services fail to meet Medicare’s medical necessity guidelines
- The services are screening services that are provided more frequently than Medicare provides a benefit for
- The services are custodial in nature
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Minimize hassles for providers. This includes limiting the volume of medical records RACs may request, and allowing RACs to look back three years instead of four.In addition, CMS is requiring RACs accept imaged records on CD/DVD.
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Maximize transparency. Among other steps, CMS has made it mandatory for RACS to have a Web site showing status of every claim by 2010, as well as send out detailed letters to providers reviewing results. The Web sites will also post types of audits as well as vulnerabilities.
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Maximize accuracy. CMS has required RACs to have medical directors and certified coders (i.e., coders with CCF, CCA, CCSP, CPC, CPC-H, or CRNC credentials).
In addition, during the call, CMS recommended providers take certain steps to prepare for the permanent RAC program. Suggested steps include the following:
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Review and understand all documents from the RAC demonstration
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Review all findings by permanent RACs once the program begins
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Review all current OIG reports at www.oig.hhs.gov/reports.asp
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Review the information on the CMS Comprehensive Error Rate Testing (CERT) Web site at www.cms.hhs.gov/cert
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Put in place an internal audit program
CMS will be holding a special RAC Open Door Forum for Part B providers Thursday, November 13, at 2:00 p.m., ET. If you missed the similar call for Part A providers November 12, a recording will be available on the CMS Web site beginning November 19.
Tip: If you plan on dialing in for the RAC Open Door Forum call for Part B providers on November 13, do so early. You may dial in as early as 1:45 p.m. ET. The November 12 call reached maximum capacity well before 2:00 p.m. ET.
“The bottom line is, from where I sit, RACs are here to stay and this little hiccup, even if lasts 90 days, will be an insignificant and long-forgotten bump in the road by next year.”
—Kenneth R. Rubin, MD, MA, MSHCM, FACEP, principal, ExpertAppeals.com
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