Revenue Cycle Institute » Billing and reimbursement

Tip: Submitting claims for laboratory services

Compliance Monitor — Thu, 19 Nov 2009 05:00:00 +0000

Your hospital should ensure that all claims for clinical and diagnostic laboratory testing services are accurate and correctly identify the services ordered by the physician (or other authorized requestor) and performed by the laboratory. The OIG recommends that your hospital’s written policies and procedures state that:

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 current procedural terminology or Healthcare Common Procedural Coding System code used by the billing staff accurately describes the service ordered
The coding staff submit only diagnostic information obtained from qualified personnel and contact the appropriate personnel to obtain diagnostic information in the event that 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
Routine audits be conducted to assess your billing compliance with the regulations

This week’s tip was adapted from The Compliance Officer’s Handbook 2^nd Edition. For more information about the book or to order your copy, visit the HCMarketplace.

CMS Public Events: Hospital Open Door Forum

Medicare Weekly Update — Tue, 17 Nov 2009 05:00:00 +0000

The next Hospital & Hospital Quality Open Door Forum is scheduled for 2 p.m. Eastern, Thursday, November 19. To access the call, 800/837-1935 and reference conference ID: 34708559.

A transcript and audio recording of the conference call will be available to MedicareFind subscribers approximately one week after the Open Door Forum is held.

RAC vs. CERT audits: Do you know the difference?

The RAC Report — Thu, 12 Nov 2009 06:00:00 +0000

The Comprehensive Error Rate Testing (CERT) Hospital Payment Monitoring Program is one of the ways CMS is trying to improve the quality and accuracy of Medicare claim submission and payment of those claims. Is that so different from what the RAC program is designed to do?

While the end-goal may be the same, the methodology is very different. Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City, outlines some of the important differences between the two types of Medicare audits:

Who is being audited. RACs look for errors made by providers, but the CERT is looking for errors in payments made by carriers. Hospitals and other providers are affected because when the CERT looks into a claim, the provider must submit the medical records, and if the CERT uncovers an error, the CERT will take back money from the hospital. But the CERT is really looking for errors made by fiscal intermediaries, Medicare administrative contractors, or other carriers when paying providers’ Medicare claims.
Education. “CERTs want to make sure everything is on the up and up for the claims,” Levitt explains. When the patterns of incorrectly paid claims appear on its radar, the CERT steps in and educates providers. RACs don’t provide such education.
Payment. RACs are paid through contingency fees. The more under- or over-payments they uncover, the more money they receive. The payment for CERTs is different; they receive a set amount outlined in their contract, regardless of the percentage of payment errors they find.
Size of the program. The RAC program has gotten much more attention than the CERT program, but it may be because the RAC program has the potential to be a much bigger headache for providers. The CERTs examine random claim samples—often only looking at a very small percentage of a carrier’s claims. So the CERT would likely request only a small number of medical records from providers paid by that carrier. And the potential takeback, if any, would likely be smaller as well.

However, there are some similarities between the two programs. Both auditors report to CMS. And both will recoup money from hospitals and other providers who received overpayments.

Providers can also appeal any claims they believe were wrongly denied by a RAC or CERT. The process for RAC appeals has been widely discussed, but providers can also go through the appeal process for a CERT denial. “It’s not just a de facto takeback,” Levitt says.

In addition, CERTs will still use OIG statistical methodology. “They’re still bound to that just like the RAC is—for example if a RAC wants to extrapolate,” she notes. “Everybody is held to the same statistical standard such as the OIG statistic program, RATSTATS.”

Clearing up condition code 44 confusion

Case Management Weekly — Wed, 11 Nov 2009 05:00:00 +0000

Hospitals must meet certain criteria before they use condition code 44. Consider this example. A patient experiencing chest pain presents to a hospital Saturday night. The hospital does not have weekend case management coverage, so the physician admits the patient as an inpatient. During this time, the physician orders tests, chest x-rays, and other services.

Upon reviewing the case on Monday, the utilization review (UR) committee determines that the patient did not require inpatient admission. Note that the UR committee may never use InterQual or Milliman criteria to deny an admission. Before the hospital can assign condition code 44 and change the patient’s status, it must meet the following requirements:

The change in patient status from inpatient to outpatient is made prior to discharge or release while the beneficiary is still a patient of the hospital
The hospital has not submitted a claim to Medicare for the inpatient admission
A physician concurs with the UR committee’s decision, and his or her approval is documented in the patient’s medical record

If the hospital fulfills these requirements while the patient is still in the building, condition code 44 will allow the hospital to go back and bill all medically necessary Part B services ordered by the physician as if they had been provided in the outpatient setting. The hospital will receive payment via the outpatient prospective payment system. If the hospital cannot fulfill these requirements, it can only bill for Part B diagnostic services.

Check out the November 2009 issue of Case Management Monthly to learn more about condition code 44 requirements. You also can discover the benefits of becoming a Case Management Monthly subscriber.

For even more condition code 44 information, join HCPro December 15 for an audio conference, “Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance.” Visit the HCMarketplace to register for this program.

ZPICs have begun in Zone 4

Case Management Weekly — Wed, 11 Nov 2009 05:00:00 +0000

The following article is excerpt from HCPro’s newest resource for hospital case managers—www.CaseManagementMentor.com—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

Health Integrity LLC, the Zone Program Integrity Contractor (ZPIC) for Zone 4 (Colorado, New Mexico, Oklahoma, and Texas) has begun requesting medical records for review.

ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. ZPICs may “take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped,” according to the Medicare Program Integrity Manual.

During HCPro’s November 3 audio conference, “Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review”, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.

This information was not that surprising to Robert Wade, Esq., a partner at Baker and Daniels, LLP, in South Bend, IN. ZPICs have authority to begin reviews as soon as they are awarded a contract. Health Integrity became the Zone 4 contractor during February.

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com.

Signature for Laboratory Tests, Clarification in the MPFS Final Rule

Medicare Weekly Update — Tue, 10 Nov 2009 05:00:00 +0000

This week, I would like to review a “clarification” regarding physician signatures on orders for clinical diagnostic testing that came out in the Final Rule for Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for 2010. Although this publication is hospital-directed and we do not normally report on physician fee schedule issues, this “clarification” could affect hospital policies on obtaining signatures for the laboratory services they provide.

Click over to the MedicareMentor Blog to read more.

CMS extends comment period for proposed ESRD PPS

Medicare Weekly Update — Tue, 10 Nov 2009 05:00:00 +0000

CMS extends ESRD PPS comment period

On November 4, CMS published a notice in the Federal Register to extend the comment period on its proposal to initiate a prospective payment system (PPS) for end-stage renal disease (ESRD). The comment period on the ESRD PPS proposed rule will now end at 5 p.m., December 16.

View the notice of extension.

Submit a comment.

CMS releases 2010 OPPS final rule

Lori Levans — Tue, 03 Nov 2009 20:24:03 +0000

The 2010 OPPS final rule released on October 30 contains few surprises, but does finalize two changes that received considerable attention when CMS proposed them. “The information CMS has finalized for physician supervision and drug reimbursement are two key areas for hospital review, though for slightly different reasons,” says Jugna Shah, MPH, president of Nimitt Consulting [...]

CMS issues 2010 final rule for ambulatory surgery centers and most hospital outpatient departments

Medicare Weekly Update — Tue, 03 Nov 2009 05:00:00 +0000

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS has released a display copy of the outpatient prospective payment system (OPPS) final rule for 2010, which also includes the 2010 changes to the rules for ambulatory surgery centers (ASCs). This final rule will be published in the Federal Register on November 20. In terms of reimbursement, OPPS hospitals that meet quality indicator reporting requirements for 2010 are entitled to the “full update,” which will result in a 2.1% increase in their payments for 2010. Those OPPS hospitals that do not meet their quality indicator reporting requirements will be subject to a reduced update of 0.1% in 2010. ASCs, on the other hand, will receive a 1.2% inflation update beginning January 1, 2010.

Among the most anticipated changes in the OPPS final rule are the so-called “incident to” a physician’s services requirements. Most nonphysician outpatient therapeutic services that are provided by hospitals or critical access hospitals (CAHs) are only covered if they are provided “incident to” the services of a physician or another specified nonphysician practitioner.

Click over to the MedicareMentor Blog to read more.

AHA RAC Program Update answers provider questions

Andrea Kraynak, CPC-A — Thu, 15 Oct 2009 04:00:36 +0000

As of September 18, all four RACs were conducting automated audits, according to an October 6 American Hospital Association (AHA) RAC program update. But only 16 of the 23 audits underway were on hospital outpatient claims, according to the AHA. (The others were therefore on physician and durable medical equipment claims.) So unless your hospital is [...]

OIG plans to review Medicare, Medicaid auditing programs

Andrea Kraynak, CPC-A — Thu, 15 Oct 2009 04:00:32 +0000

Healthcare providers are finding themselves and their reimbursement claims accountable to more and more auditors as CMS steps up its Medicare and Medicaid auditing activities. And CMS is unlikely to decrease auditing for incorrectly paid claims anytime soon; it too is being held accountable—by the Office of Inspector General (OIG). In 2010, the OIG plans to [...]

September 28-October 5 Issuances: OIG issues 2010 Work Plan, CMS updates lab NCDs and RAC FAQ

Medicare Weekly Update — Tue, 06 Oct 2009 04:00:00 +0000

OIG issues Work Plan

On October 1, the OIG issued its Work Plan for FY 2010.

View the Work Plan.

CMS updates lab NCDs

CMS has posted the October 2009 update to its lab NCDs.

View the lab NCD manual.

New RAC FAQ

CMS released several new/updated FAQs, including the following:

If I am a chain provider whose FI is WPS (serving as the national fiscal intermediary) who will my Recovery Audit Contractor (RAC) be?

Read the answer.

Five Last-Minute Tips to Prepare for RACs

Andrea Kraynak, CPC-A — Fri, 02 Oct 2009 19:03:46 +0000

RACs have begun auditing at this point, and providers in some states may have received their first denial letters this week. But many providers seem to still be waiting, holding their breath, and worrying whether the mail carrier might deliver their first RAC demand letter(s) that day. However tempting it may be to simply wait, providers [...]

Q&A: Charging for behavioral therapy in the home setting

JustCoding News — Wed, 30 Sep 2009 04:00:00 +0000

QUESTION: I have a question regarding behavioral health treatment sessions. Can a physician or licensed therapist (e.g., LPC or LCSW) provide therapy to a client at the client’s home and then charge this service to the insurance company?

ANSWER: The answer depends on the third-party payer. For nonphysician professionals, coders would most often report HCPCS Level II codes. Refer to codes H0001–H2037 (Behavioral health/substance abuse services). Note that codes in this section cover a much wider scope of therapy than the heading implies. Report place of service code 12 (Home). Check with payers to determine whether they accept these codes. Also, note that CPT code 99510 (Home visit for individual, family, or marriage counseling) is used to denote services provided by a nonphysician healthcare professional.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Accurately assign POA indicators with the right info

HIM Connection — Tue, 29 Sep 2009 04:00:00 +0000

The present-on-admission (POA) indicator refers to conditions that are present at the time an order for inpatient admission occurs. Coders should report a POA indicator for a principal diagnosis, as well as any secondary diagnoses or E codes.

To assign POA, coders must rely on a treating physician’s documentation. Assuming physician documentation is accurate and complete, a coder can consider these tips when assigning a POA indicator:

Look in the history and physical, as well as the ER physician documentation and admitting progress notes and orders. The cut-off point in determining whether the condition was POA is when the admit order was written.
Look for confirming diagnoses. Perhaps the physician documented a sign or symptom on admission, but didn’t render a diagnosis until two or three days later. The physician may have documented a diagnosis as “possible” or “probable,” but didn’t confirm it until later in the progress notes. Only code a diagnosis listed as “possible” or “probable” when the condition is later confirmed or still qualified as uncertain at the time of discharge. Since the diagnosis is based on signs or symptoms that were POA, the coder would assign a “yes” indicator. Note that an uncertain diagnosis would be POA only when that diagnosis had related signs or symptoms that were present at the time of admission. Otherwise, if the signs and symptoms developed after the physician order, the diagnosis is not POA.

This tip was adapted from the HCPro book, The MS-DRG Training Handbook. For ordering information, visit the HCMarketplace.

Q&A: Coding conditions as “acute” versus “chronic”

HIM Connection — Tue, 29 Sep 2009 04:00:00 +0000

Question: A patient came into the ER with complaints of a headache and facial pain. The ER physician gave a final diagnosis of sinusitis. This patient had no history of sinusitis. After a coding review, the reviewer said we were wrong to use “acute” and told us to use “chronic.” She told us never to use “acute” unless the physician documents the condition as “acute.” We were previously under the impression that when coding ER accounts, coders should always report conditions as “acute.” Do you know of any ER coding guidelines or publications that would clear this up?

ANSWER: Coders assign codes based on physician documentation. In order to assign a code for an acute condition, the coder should see clearly that the physician documented it as acute. Many ICD-9-CM codes, like sinusitis, default to a chronic status without further specification by the physician.

Sinusitis (accessory) (nasal) (hyperplastic) (nonpurulent) (purulent) (chronic) 473.9

Coders should not assign codes based on the setting in which the physician provided the services. Patients could present to the ER for care related to a chronic condition as well as an acute condition.

Editor’s note: Shannon McCall, RHIA, CCS, CCS-P, CPC-I, CCDS, director of HIM and coding for HCPro, Inc., in Marblehead, MA answered this question in the October issue of Briefings on Coding Compliance Strategies.

September 21-28 Transmittals and MLN Matters articles: CMS updates drug HCPCS hook and hold, rescinds/replaces transmittals, and more

Medicare Weekly Update — Tue, 29 Sep 2009 04:00:00 +0000

CMS rescinds, replaces LCD exception transmittal

On September 25, CMS replaced its previous transmittal on LCD exceptions. It had previously sent out the incorrect version of section 3.12. All other material remains the same.

Effective date: October 13, 2009
Implementation date: October 13, 2009

View the transmittal.

CMS rescinds, replaces transmittal on NCDs for surgical never events

On September 25, CMS replaced its previous transmittal on its surgical never event NCDs. CMS made several clarifications in the new issuance.

Effective date: January 15, 2009
Implementation date: July 6, 2009, for B MACs and carriers; October 5, 2009, for A MACs, FIS, and FISS

View the transmittal.

CMS updates OPPS hook and hold for certain drug HCPCS

On September 25, CMS issued instructions to update the hook program for certain drug HCPCS codes.

Effective date: January 1, 2010
Implementation date: January 4, 2010

View the transmittal.

MLN Matters article

CMS released a special edition MLN Matters article on influenza resources.

2009 - 2010 Seasonal Influenza (Flu) Resources for Health Care Professionals

Condition Code 44 – The Next Chapter

Medicare Weekly Update — Tue, 29 Sep 2009 04:00:00 +0000

Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

After CMS issued Transmittal 1803, we have continued to receive questions on the correct way to bill for outpatient services when Condition Code 44 criteria have been met. The next chapter of the story involves determining if and when observation begins.

Click over to the MedicareMentor Blog to read more.

Find a physician advisor in your organization

Case Management Weekly — Wed, 23 Sep 2009 04:00:00 +0000

If your facility has identified the need for a physician advisor (PA), a great place to begin searching for the ideal candidate is within your organization.

Hiring a physician who has been on the medical staff for at least three to five years may be beneficial. These individuals already know the hospital system, physicians, policies, and politics.

Determine which active medical staff members are very knowledgeable with respect to medical necessity and length of stay (LOS) issues, practice high-quality evidence-based medicine, communicate effectively, and use hospital resources responsibly. Then observe them during committee and department meetings to assess how they relate to their peers. Once you identify individuals who meet these qualifications, approaching them to inquire whether they have interest in working as a PA might be worthwhile.

This tip was adapted from the HCPro book, Optimizing the Physician Advisor in Case Management. To learn more about this book or order your copy, click here.

Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to Associate Editor Ben Amirault at bamirault@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!

September 14-21 Transmittals and MLN Matters articles: CMS rescinds/replaces transmittals, issues special edition MLN Matters

Medicare Weekly Update — Tue, 22 Sep 2009 12:44:00 +0000

CMS replaces FDG PET transmittals

On September 18, CMS rescinded and replaced two previous transmittals related to FDG PET coverage.

Effective date: April 6, 2009
Implementation date: October 19, 2009

View the transmittal to the Claims Processing Manual.

View the transmittal to the National Coverage Determinations Manual.

CMS replaces IPPS update transmittal

On September 17, CMS rescinded and replaced its previous transmittal to update the IPPS.

Effective date: Discharges on or after October 1, 2009
Implementation date: October 5, 2009

View the transmittal.

View a related MLN Matters article.

MLN Matters article

CMS issued a Special Edition MLN Matters article.

Visit Requirements Clarification for CR 5931 “Manualization of Payment for Outpatient ESRD Related Services”