Archive for: Coding
Cope with a new MAC
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro
This week, CMS announced National Heritage Insurance Company (NHIC) as the A/B MAC for the New England jurisdiction (Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). NHIC was primarily a Part B carrier prior to its selection as an A/B MAC for the northwest (Washington, Oregon, Idaho and Alaska), and now for New England. Many former students have discussed with me the difficulties they have experienced transitioning to a new contractor. This difficulty has been exaggerated in locations where the new contractor was formerly Part B carrier focused. This is presumably due to the very different coding, reimbursement, and even coverage environments of the services provided by suppliers (formerly billed to carriers) and those provided by institutional providers, such as hospitals.
I encourage everyone in these states, and anyone affected by a MAC transition, to review the Special Edition MLN Matters Article SE0837. It discusses steps providers can take to minimize problems during the transition, what to expect for process changes and possible disruptions to cash flow, and how to avoid them. I encourage everyone to pay particular attention to the possible changes to the local coverage determinations, including determinations of self-administered drugs. These may change under a new MAC, and the effective dates of changes can be confusing and have to be monitored closely to ensure you are notifying your patients appropriately of noncovered services.
Tip: Submission of claims for laboratory services
A hospital should ensure 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 a hospital’s written policies and procedures require:
- 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
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
OPPS final rule appears in November 18 Federal Register
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.
Change to ICD-10-CM anticipated
The Centers for Medicare and Medicaid Services (CMS) is expected to soon alter one of the coding systems that hospitals rely on to bill insurers–a change that some say is necessary, but that could also initially cause confusion for physicians and consumers accustomed to the ICD-9-CM coding system, the Wall Street Journal reports.
CMS corrects definitions of nonselective angiography codes
By Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.
In 2003, CMS published revised definitions for two codes (G0275 and G0278), which describe non-selective renal and iliac/femoral artery angiography performed at the time of cardiac catheterization or coronary angiography. When these codes appeared in the HCPCS data file published by CMS, the long descriptors left out the word “non-selective.” This led to some confusion because the HCPCS Level II books are published based on CMS’ official HCPCS data file, and therefore also contained the incorrect descriptor for these codes. This error left many providers concerned that these codes were for “selective” angiography and were actually replacement codes for the “selective” CPT codes that already existed.
At that time, Hugh Aaron wrote to CMS and received confirmation that the codes were for “non-selective” angiography, and that the HCPCS data file would be corrected the following year. However, the following year’s file still contained the old long descriptors, omitting the word “non-selective.” Hugh wrote to CMS in subsequent years to bring this oversight to its attention, but the codes remained incorrect in the published data file, even though the CMS representative continued to confirm that the codes were for “non-selective” angiographies. In November 2007, when the 2008 HCPCS data file was released, I personally wrote to a CMS representative to bring to their attention that the code descriptors were still incorrect. I was assured that they would be corrected the following year.
This week, CMS released the 2009 HCPCS data file, containing the correct long descriptors, including the word “non-selective.” This update should avoid confusion on the use of these codes. Providers should review their coding of angiographies to ensure they are and were coding using the correct descriptors for these two codes.
November 3-10 CMS Transmittals and MLN Matters articles
CMS issues annual update to the Healthcare Common Procedure Coding System (HCPCS)
On November 7, CMS issued a transmittal implementing an update to HCPCS for 2009.
Effective date: January 1, 2009
Implementation date: January 5, 2009
View the transmittal.
CMS updates Medicare deductible, coinsurance, and premium rates for 2009
On November 7, CMS issued a transmittal updating the rates for deductibles, coinsurance, and premiums in 2009.
Effective date: January 1, 2009
Implementation date: January 5, 2009
View the transmittal.
CMS updates previous transmittal on payment for implanted prosthetic devices for Part B inpatients in hospitals paid under the Medicare hospital Outpatient Prospective Payment System (OPPS)
On November 3, CMS rescinded and replaced its September 12, 2008, transmittal (Change Request 6050) on payment for implanted prosthetic devices for Part B inpatients in hospitals paid under the OPPS. A new C code, C9899, was not included until the release of the HCPCS contractor file. All other information remains the same.
Effective date: January 1, 2009
Implementation date: January 5, 2009
View the transmittal.
View a related MLN Matters article.
CMS updates Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) rates
On October 31, CMS issued an update to the visit rates for RHCs and FQHCs.
Effective date: January 1, 2009
Implementation date: January 5, 2009
View the transmittal.
View a related MLN Matters article.
CMS updates therapy code list
On October 31, CMS issued the annual update to the list of codes that sometimes or always describe therapy services. The Medicare Claims Processing Manual, Chapter 5, § 20, has a full list of sometimes and always therapy service codes.
Effective date: January 1, 2009
Implementation date: January 5, 2009
View the transmittal.
View a related MLN Matters article.
CMS provides influenza vaccine and the pneumococcal vaccine payment allowances based on 95% of the average wholesale price (AWP)
On October 31, CMS issued a transmittal providing the payment allowances for influenza and pneumococcal vaccines when payment is based on 95% of the AWP.
Effective date: September 1, 2008
Implementation date: No later than December 1, 2008
View the transmittal.
View a related MLN Matters article.
CMS implements new hemophilia clotting factor HCPCS code
On October 24, CMS issued a transmittal implementing a new hemophilia clotting factor HCPCS code, J7186, as payable under Medicare, and terminating Q4096.
Effective date: January 1, 2009
Implementation date: April 6, 2009
View the transmittal.
View a related MLN Matters article.
A snapshot of RACs today and a glimpse of what lies ahead
by Denise Nash, MD, CCS, CIM
In the recovery audit contractor (RAC) demonstration project, which began in 2005, CMS authorized contractors to review payments dating as far back as four years and target DRGs that were likely to result in overpayments.
CMS determined that for fiscal year 2006, 97% of improper payments were overpayments and 3% were underpayments.
Thus far, 94% of the money RACs have collected has been from hospitals and durable medical equipment claims and 6% from physicians.
Face it folks, the RACs are here to stay.
What did RACs discover?
Since their inception, RACs have uncovered a number of overpayments, many of which have stemmed from errors in DRG assignment; coding; and payment for noncovered services, claims that don’t meet medical necessity requirements, and duplicate claims.
For example, consider a claim in which a patient presents to the emergency department with shortness of breath. The electrocardiogram is normal, and the chest x-ray rules out pneumonia. The patient is admitted for a one-day stay; however, a RAC review finds that the facility could have treated the patient on an outpatient basis. So the RAC denies this claim because it did not meet the medical necessity requirements.
RACs also targeted other DRGs that often fail to meet medical necessity requirements (e.g., DRG 243, medical back problems).
DRG 416, sepsis and septicemia, always seems to crop up on any audit, the RAC is no exception. Is it bacteremia versus sepsis? Is it urosepsis versus a urinary tract infection? Again, audit ICD-9-CM code assignments to ensure they meet the requirements for reporting DRG 416 versus DRGs 320/321, 331, 332, or 144.
RACs also identified cases in which there is the greatest probability of a DRG change. For example, DRG 217 (wound debridement and skin graft procedures, except hand and CT disorders) and DRG 263 (skin graft and /or wound debridement) often involve incorrect assignment of the debridement code (e.g., 86.22, excisional debridement and 86.28, nonexcisional debridement).
Note that RACs consider documentation that states “sharp debridement” insufficient for coders to assign code 86.22. Likewise, documentation that states “use of scissors” is not substantial without explicit documentation of the term “excisional.”
RACs also examined diagnoses (e.g., osteomyelitis, necrotizing fasciitis, amputation site infection, and skin/decubitus ulcer) associated with the debridement. Note that when the debridement is part of another, more invasive procedure, coders should not assign debridement code 86.22.
To address these target DRGs, audit your inpatient debridement procedures, and look for errors for DRGs 217, 263, 440,415, 226/227, 537/538, and 269/270. Also, look at the quality of your debridement documentation and code capture accuracy.
Where should you go from here?
Determine your process for responding to a RAC request for medical records and request to review your internal records compliance. What is your chain of command for handling these requests?
One facility where I worked had established the compliance office as command central for comprehensive error rate testing. The facility maintained a log of the request letters because they noticed duplicate record requests for the same patient.
Because the RAC process is somewhat similar, I would venture that these efforts related to the RAC should also be incorporated into the same department. Other facilities may want this function to reside within their medical records department. It doesn’t matter where the function resides as long as there is accountability.
Create a system to track the RAC audit process. Some facilities receive 10–100 RAC requests each month, whereas others receive this same number of requests in a day.
How can you track RAC requests and findings?
You may want your information system department to set up a database to track requests. You may then be able to run queries on this data.
This data can serve as an educational tool for coders as well as providers. You may also be able to mine the data for the number of records requested or denied per day/month/year and the total financial impact to the organization.
You can also use this type of tracking mechanism to justify hiring new personnel or dedicating existing personnel to this function since the turnaround time can be tight. Remember that you must copy and send the requested medical records to the RAC within 45 days of receipt of the request. If the record(s) is not submitted, Medicare will issue a technical denial to your facility.
One other point to note is that RACs do not accept retrospective physician queries as supporting documentation in rebuttal to an old case, so you may want to enhance your facility’s physician query process.
Regulations change each year, so if you have a small practice and cannot afford to maintain a staff member who is dedicated to compliance, at the very least, designate someone to keep up with all regulatory changes. You may also want to hire a consultant to help you stay up-to-date on regulation changes.
How can you review RAC findings?
Overpayment does not mean intentional fraud. It could result from a different interpretation of the rules or from a payer’s payment error or inaccurate code assignment for the service billed.
Facilities and practices may appeal the RACs findings. Keep in mind, however, that when you appeal a case, interest rates on overpayments accrues. If Medicare denies the appeal, the entity is obligated to pay the interest in addition to the overpayment.
Again, small practices should plan to designate someone in the office who can repudiate RAC findings when necessary or hire a reputable consultant to aid with this process. After all, RACs have a vested interest in finding errors because the contingency fees they earn are a percentage of the payments they collect from healthcare providers. So it’s important to carefully review their assessments.
Also, note that because of the RACs’ success, commercial insurers are also beginning to use these agencies.
How do you prepare for the RAC?
Remember, RACs may not always be right. Establish a process to effectively examine your RAC’s findings. Your plan should include the following steps:
- Look at admission errors. Focus on short-term hospital stays, and review why they were short stays.
- Use a multidisciplinary team approach, and involve staff members from your compliance, coding, and case management departments.
- Develop internal appeals guidelines and create a standardized letter.
- Educate your team on the critical turnaround time of 45 days for RAC requests.
- Analyze RAC findings and any errors the RAC encounters.
- Determine systemic issues, if any. This should decrease denied claims and diminish future risk.
- Educate all parties about chart documentation and code capture to correct issues and avoid similar findings in the future.
- Conduct internal audits, and be proactive.
The permanent RACs will be able to review claims only as far back as October 1, 2007, so work forward from that date. Monitor the OIG Work Plan, and educate your staff members about the target DRGs. Look at your program for evaluating the payment patterns electronic report (PEPPER) to evaluate your facility’s potential risk of overcoding and unnecessary admissions.
In a facility or large medical group, staff members should conduct pre-emptive audits. A smaller facility or physician group that does not have an internal audit or compliance department may want to invest in a consultant for an initial audit to pinpoint areas of exposure, especially related to physician documentation improvement.
Editor’s note: Denise Nash is a senior consultant with Accuro Pricing Solutions in Dallas, a MedAssets Company. This article originally appeared on the JustCoding.com Web site.
CMS releases 2009 OPPS final rule
Less restrictive conditions for coverage (CfC) for ambulatory surgery centers (ASC), new composite APCs, and revised definitions for new and established patients are among the provisions of the outpatient prospective payment system (OPPS) final rule for calendar year (CY) 2009. CMS released the 2009 OPPS final rule as a display copy on October 31.
In a CMS news release, CMS Acting Administrator Kerry Weems says, “In this final rule, we are continuing to pay appropriately for care while working with health care providers as we look for ways to make sure beneficiaries who come in for treatment of one complaint don’t leave with two as a result of adverse events during their outpatient visits.”
The rule also establishes new CfCs for ASCs that reflect current ASC practice by focusing on the care provided to patients and the impact of that care on patient outcomes. The final rule defines an ASC as a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.
A news release on the Web site of the Ambulatory Surgery Center Association says the CfCs are less restrictive than a revision CMS proposed last year.
Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC, says her quick review of the final rule indicates that CMS appears to have moved forward with the majority of its proposals, despite concerns expressed by numerous commenters on sensitive issues, such as the creation of new imaging composite APCs and further decreases in drug reimbursement.
Packaging and composite APCs
CMS continues to expand its concepts of packaging and composite APCs as mechanisms to promote provider efficiency. “This is clearly evidenced by CMS’ tone throughout the rule and, in particular, with its finalization of the multiple imaging composite APCs, the elimination of the IVIG pre-administration HCPCS G0332 separate payment, and its persistence in keeping all diagnostic radiopharmaceuticals packaged despite well-thought-out arguments brought forth by commenters,” says Shah.
CMS has decided to move forward with its multiple imaging composite methodology, which means it will provide a single composite APC payment each time a hospital bills more than one procedure from an imaging family on a single date of service. Shah says providers should examine the financial impact of this measure by evaluating the number and types of imaging services they regularly provide on a given date of service, as CMS is not distinguishing between multiple services provided on the same date of service in the same session and multiple services provided on the same day at two different sessions.
Separately payable drugs
Shah notes that although CMS has shown an interest in further exploring the pharmacy stakeholder proposal to allocate a portion of packaged drug costs to cover pharmacy overhead costs, it has not moved forward with this for 2009 and instead has finalized its proposal that all separately payable drugs will be paid at average sales price (ASP) plus 4%.
“This additional decrease in separately payable drug reimbursement is disappointing given the compelling arguments that provider and industry groups have made highlighting that ASP plus 4% in no way comes close to covering both the drug acquisition and pharmacy overhead cost,” Shah says. “[It] could leave hospitals facing a larger than expected financial impact, especially when taken together with a number of the other changes CMS has finalized for 2009.”
However, CMS abandoned its proposal to create two new costs centers for drugs—drugs with low overhead costs and drugs with high overhead costs—in response to commenter objections. “This is good news indeed and it’s great that so many providers and industry organizations commented, and that CMS listened,” says Shah.
E/M visit codes
For 2009, CMS has chosen to maintain the use of evaluation and management (E/M) CPT codes distinguishing between new and established patients, while acknowledging the merits of many commenter suggestions. However, the agency has revised the definitions of new and established patients.
“This is a really a mixed bag of news for providers,” says Shah. “Providers have to continue living with a distinction that most hospitals don’t seem to support, but at least CMS has revised the definition, which should make the reporting of new vs. established patients easier.”
Quality reporting
Four new measures for outpatient quality reporting appear in the final rule. These are all for imaging, and CMS states that it can compute the quality measure/score based on claims data.
Editor’s note: For more information on the CY 2009 proposed rule for the OPPS, go to the CMS Web site: www.cms.hhs.gov/HospitalOutpatientPPS
For more information on the ASC payment system, go to the CMS Web site: www.cms.hhs.gov/ASCPayment/.
The 2009 OPPS final rule will be published in the November 18 Federal Register.
CMS posts 2009 OPPS final rule fact sheets
By Hugh E. Aaron, MHA, JD, CPC, CPC-H
The big news last week was the release of the display copy of 2009 OPPS final rule. The display copy is 1,827 pages, which may be a record. Those of you looking for a quick overview of the final rule should review the two fact sheets listed below. The first fact sheet provides a general overview of the 2009 OPPS changes. The second fact sheet provides an overview of 2009 changes relating to drugs, biologicals, and radiopharmaceuticals furnished in a hospital outpatient setting. The final rule is scheduled for publication in the November 18 Federal Register.
CMS Transmittals and MLN Matters articles
CMS issues MLN Matters articles
CMS released two MLN Matters articles last week related to transmittals previously announced in Medicare Weekly Update.
- October 2008 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 14.3, Effective October 1, 2008
