Training Programs
Audits & Assessments
Regulatory MonitoringArchive for billing
- 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
Q: 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?
Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.
On July 31, 2009, CMS issued the IPPS final rule announcing the changes that will affect the payment rates and related policies for acute care hospitals and long-term care hospitals that are paid under the prospective payment system. The changes are effective for discharges beginning on October 1, 2009 which is the start of the government’s fiscal year for 2010 (FY2010).
Though many hospitals had feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31.
CMS had originally proposed a documentation and coding adjustment to account for the "effect of increases in aggregate payments due to changes in hospital coding practices that do not reflect increases in patient’s severity of illness," according to CMS.
However, CMS states it will continue to research the effects of the MS-DRG transition, including performing a complete analysis of FY 2008 and FY 2009 data. The agency may consider phasing in future adjustments over an extended period beginning in FY 2011, according to a CMS press release.
In addition, CMS expands the number of quality measures hospitals must report to be eligible for a full market basket update in FY 2011. New measures include Surgical Care Improvement Project (SCIP) Infection 9 (Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2) and SCIP INF 10 (Surgery Patients with Perioperative Temperature Management).
The agency will not make any changes to the list of hospital-acquired conditions. It will, however, evaluate the impact of the existing policy on hospital practices and care.
To view the final rule, visit www.cms.hhs.gov/AcuteInpatientPPS/01_overview.asp.
Editor's note: Visit the Revenue Cycle Institute later today for additional analysis of the IPPS final rule.
OIG issues reports on oxaliplatin billing
On July 1, the OIG issued two reports on oxaliplatin billing at Kootenai Medical Center and University of California San Diego Medical Center. The OIG found that both organizations billed incorrectly for oxaliplatin and received overpayments.
OIG issues reports on payments for Epogen
On June 24, the OIG issued two audit reports on Epogen billing at Fresenius Medical Care-Wynnewood and Lancaster General Hospital Dialysis Center. The OIG found that both organizations received overpayments.
Join MedicareFind today for direct links to all the documents in our regulatory database.
May 4-11 Issuances: OIG releases reports, CMS proposes decision memo, and more
OIG issues review of oxaliplatin billing at Providence Alaska Medical Center
On May 8, the OIG issued a review of oxaliplatin billing at Providence Alaska Medical Center for calendar year 2005. The OIG found that Providence Alaska billed Medicare for an incorrect number of service units for one oxaliplatin outpatient claim and received an overpayment of approximately $31,000.
OIG issues review of separately billed lab tests paid by National Government Services, Inc., for ESRD beneficiaries
On May 6, the OIG released a review of separately billed lab tests paid by National Government Services (NGS), a Medicare fiscal intermediary, for laboratory tests that dialysis facilities provided to end-stage renal disease (ESRD) beneficiaries. The OIG estimated that NGS overpaid dialysis facilities $3.9 million for laboratory tests provided to ESRD beneficiaries during calendar years 2004-2006.
CMS issues proposed decision memo for pharmacogenomic testing to predict warfarin response
On May 6, CMS published a proposed decision memo in which it proposed that pharmacogenomic testing to predict warfarin responsiveness is covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin and only then in the context of a prospective, randomized, controlled clinical study when that study meets certain standards.
View the proposed decision memo.
Frequently asked questions
Last week, CMS released several new/updated frequently asked questions (FAQ) last week related to Medicare fee-for-service payment, coding, and billing.
- On contingency fees: RACs receive the same contingency fee regardless of whether they identify over- or underpayments.
- On medical record request limits: If your medical record request limit is per NPI, listen up. The record request limit is based on your group NPIs, not the number of NPIs assigned to your individual physicians. This could be an issue, explains Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc. “An 18-member physician practice group that has a group NPI could expect requests of 50 medical records every 45 days, whereas if this same medical group issues a different group NPI to each of its three practice locations (each of which have six doctors), the physician practice group could have up to 30 medical records requested for each of the three groups—for a total of 90 medical records every 45 days.”
- On line-item billing: For a claim containing multiple CPT codes for the same date of service, each code (i.e., procedure) constitutes an item that RACs can review. Beckley believes this may come as a surprise to many providers who may consider a visit (which could encompass several CPT codes) as a claim for a date of service.
- On submitting electronic claims: The RACs currently aren’t set up to receive electronic data interchange—nor will they be for some time. For now, submit paper claims (via fax is fine) or send images of electronic medical records via CD or DVD.
- On outreach sessions: If you are in a blue state, you will start seeing outreach sessions in your area beginning in August. If you are a yellow or green state, you should see sessions in your area soon. CMS will update its outreach schedule as it adds sessions. If you are a yellow or green state and believe CMS has no outreach sessions applicable to your organization in your area, e-mail CMS at RAC@cms.hhs.gov. CMS also plans to provide an outreach presentation on its Web site. CMS acknowledged during the call’s Q&A section that hospital associations and medical societies hosting the provider outreach sessions may have limited participation to “members only” leaving nonhospital or nonphysician providers (e.g., physical therapy clinics or DME providers) without an opportunity to attend a session, says Beckley.
Get blog updates in your e-mail
Subscribe to our free RAC Report e-zine
