HPP – Accuchecker
Health Plans Path, Corp
ACK Bulletin
Provider Operations
hppaccuchecker@gmail.com
07/August/2013
Reporting place of service (POS) codes
Physicians are required to report the place of
service (POS) on all health insurance claims they submit to Medicare Part B
contractors. The POS code is used to identify where the procedure is furnished.
Physicians are paid for services according to the Medicare physician fee
schedule. This schedule is based on a payment system that includes three major
categories, which drive the reimbursement for physician services:
• Practice expense
• Physician work
• Malpractice insurance
It is important to know that practice expense
reflects the overhead costs involved when providing a service.
To account for the increased practice expense
physicians incur by performing services in their offices, Medicare reimburses
physicians a higher amount for services performed in their offices (POS code
11) than in an outpatient hospital (POS 22-23) or an ambulatory surgical center
(ASC) (POS 24).
Therefore, it is important to know the POS also
plays a factor in the reimbursement.
The POS code is entered in the 2400 Place of
Service Code loop (segment SV105) of the 837P electronic claim (Item 24B on the
CMS-1500 paper claim form). This is a required field. Always ensure you
are using the correct POS code to identify the service location for each item
used or service performed and billed on the claim.
Medicare claim completion instructions
specifically state that each provider or practitioner is responsible for
becoming familiar with Medicare coverage and billing requirements. Some
physician offices submit their own claims to Medicare contractors; other
offices hire billing services to submit their claims. Physicians are
responsible for all Medicare payments generated to them, regardless of claim
submission choice (electronic or paper).
All carriers are stressing to physicians and
their billing agents the importance of reporting the correct POS code. For
example, billing physician's office (POS 11) for a minor surgical procedure
that is actually performed in a hospital outpatient department (POS 22) and
collecting a higher payment is inappropriate billing and may be viewed as
program abuse.
It is imperative that you have internal control systems in place
to prevent Medicare billings with incorrect place of service codes.
ELECTROCARDIOGRAM
(ECG OR EKG)
Payment for electrocardiograms
as indicated below.
Electrocardiograms
are indicated in the evaluation of disorders of cardiac rhythm, anatomy,
coronary
blood flow, myocardial function; of symptoms related to such disorders; as an
adjunct in the assessment of certain drug toxicities and metabolic disorders.
However,
there are no data that show that routine EKGs performed as a screen for
coronary
heart
disease (CHD) during a preventive visit, or during an office visit when there
are no
cardiovascular
symptoms, is of benefit. The United States Preventative Services Task Force has
studied
this issue, and recommends against routine screening with resting EKG in adults
at low
risk
for coronary heart disease (CHD) events. The USPSTF found at least fair
evidence that a
routine
screening EKG for this population is ineffective or that harms outweigh
benefits. The
USPSTF
states that the consequences of false-positive tests may potentially outweigh
the
benefits
of screening. False positive tests are common among asymptomatic adults,
especially
women,
and may lead to unnecessary diagnostic testing, over-treatment, and labeling.
The
USPSTF found at least fair evidence that EKG can detect some asymptomatic
adults at
increased
risk for CHD independent of conventional CHD risk factors. The USPTF concluded
that there was insufficient evidence to recommend for or against routine
screening with EKG in adults at increased risk for CHD events.
Major
independent risk factors for CHD are (1)
Cigarette smoking (2) Elevated blood pressure (3) Elevated serum total (and
LDL) cholesterol (4) Low serum HDL cholesterol (5) Diabetes mellitus, and (6)
Advancing age. According to the risk stratification data, the presence of
advanced or advancing age alone, without at least one of the Major independent
risk factors, does not take a patient out of the low risk category. Therefore,
a Member, at any age, without symptoms or a diagnosis reflecting one of the 6
risk factors listed above, will be in a low risk category. Codes for all of
these risk factors are found in the list of ICD9 diagnostic codes below.
Patients
who have no cardiac symptoms or history of cardiac events, but with a family
history of premature cardiovascular disease (first-degree relative with an
event earlier than age 55) should have an appropriate cardiovascular work-up.
Testing should include evaluation of all cardiac risk factors. A resting EKG
alone is not an adequate evaluation for such a patient. Depending on the results
of a resting EKG, coronary artery evaluation is done by a standard treadmill
stress test, a nuclear perfusion imaged stress test, or a stress echocardiogram
test.
Patients
with a family history of premature cardiovascular disease, who also have either
cardiac
symptoms
or the presence of one independent risk factor other than age (placing them in
the
intermediate
or high-risk group), will have the EKG reimbursed when coded with the risk
factor or symptom that they have.
Those
patients with a family history of premature cardiovascular disease, with no
symptoms,
and
no independent risk factors, other than age, who are therefore in the low-risk
group according to the Framingham criteria, will have an EKG reimbursed under
the following circumstances:
If
used to determine which type of stress test a patient should undergo, a resting
EKG will be
reimbursed
with a family history of premature cardiovascular disease.
There
is no ICD 9 code specific for a family history of pre-mature cardiovascular
disease.
Providers
should code the EKG with the diagnostic ICD 9 code of V17.3, Family history of
ischemic
heart disease, or V17.49, Family history of other cardiovascular diseases. EKGs
for
Patients with these diagnoses
will be reimbursed assuming that the appropriate stress test is
performed within four (4) months.
Furthermore, CMS has a non-coverage
policy for a routine screening EKG:
ICD-10 Codes (Preview
Draft)
In preparation for the transition
from ICD-9 to ICD-10 medical coding on October 1, 2014, a
sample listing of the ICD-10 CM
and/or ICD-10 PCS codes associated with this policy has been
provided below for your
reference. This list of codes may not be all inclusive and will be updated
by Accuchecker to reflect any applicable revisions to the ICD-10 code
set and/or clinical guidelines outlined in this policy.
Diagnosis Code
(Effective 10/01/14) and Description
FOR LISTING OF DIAGNOSIS - CONTACT Accuchecker Support at:
hppaccuchecker@gmail.com
Other News: {Updates
from CMS}
Final
ICD-9-CM Code Set Update
CMS announces the final updates to
ICD-9-CM codes will take effect on October 1, 2013. These updates will be in
effect until the ICD-10 transition takes place on October 1, 2014.
CMS imposes
first Affordable Care Act enrollment moratoria to combat fraud
Agency targets high-fraud areas while ensuring patient access to care
Building on strong anti-fraud efforts
already underway, Centers for Medicare & Medicaid Services’ (CMS)
Administrator Marilyn Tavenner today announced temporary moratoria on the
enrollment of new home health provider and ambulance supplier enrollments in
Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) in three
fraud “hot spot” areas of the country. The goal of the temporary
moratoria is to fight fraud and safeguard taxpayer dollars, while ensuring
patient access to care. Authority to impose such moratoria was included
in the Affordable Care Act, and CMS is exercising this authority for the first
time.
Under the moratoria, existing providers
and suppliers can continue to deliver and bill for services, but no new
provider and supplier applications will be approved in these areas for all
three programs. The temporary enrollment moratoria apply to newly-enrolling
home health agencies in the Miami and Chicago metropolitan areas; and
newly-enrolling ground ambulance suppliers in the Houston metropolitan area
(see list of affected counties below). CMS announced the temporary,
six-month moratoria in a notice issued today in the Federal Register.
“CMS is using all available tools,
including these moratoria, to combat fraud, waste and abuse in these vital
health care programs,” said Administrator Tavenner. “While maintaining
patients’ access to care, we are putting would-be fraudsters on notice that we
will find and stop them before they can attempt to bill Medicare, Medicaid and
CHIP.”
CMS carefully examined Medicare
beneficiary access to home health and ambulance services in the Miami, Chicago
and Houston areas, and concluded that the moratoria will not affect access to
care. The agency also worked closely with the states of Florida, Illinois and
Texas to evaluate patient access to care, and these states reported that
Medicaid and CHIP beneficiaries will continue to have access to services.
During the moratoria period, CMS and states will continuously monitor access to
care to ensure Medicare, Medicaid and CHIP beneficiaries are receiving the
services they need.
In consultation with the Health and
Human Services Office of Inspector General and the Department of Justice, CMS
reported that fraud trends warranted a moratorium on home health providers and
ambulance suppliers in three geographic areas. CMS also reviewed key
factors which are indicators of potential fraud risk including a
disproportionate number of providers and suppliers relative to beneficiaries, a
rapid increase in enrollment applications from providers and suppliers, and
extremely high utilization. All three areas ranked near the top across
the nation on all of these fraud risk factors. Federal law enforcement
agencies have also pursued and prosecuted a large number of cases of health
care fraud in these areas. CMS is working with its partners to monitor the
impact of the moratoria, such as the anticipated movement of fraud schemes to
different services or geographic areas.
The moratoria begin Tuesday, July 30.
CMS may lift the moratoria earlier or extend it another six months by
issuing another notice in the Federal Register. The affected counties in
each of the three metropolitan areas are:
·
Miami: Miami-Dade and Monroe
·
Chicago: Cook, DuPage, Kane, Lake, McHenry and Will
·
Houston: Brazoria, Chambers, Fort Bend, Galveston,
Harris, Liberty, Montgomery and Waller
The Affordable Care Act has enabled CMS
to expand efforts to prevent and fight fraud, waste and abuse. Over the
last four years, the Obama administration has recovered over $14.9 billion in
healthcare fraud judgments, settlements, and administrative impositions,
including record recoveries in 2011 and 2012.
In addition, CMS has revoked 14,663
providers and suppliers’ ability to bill in the Medicare program since March
2011. These providers were removed from the program for a variety of reasons,
such as felony convictions, not being in operation at the address CMS had on
file, or otherwise not being in compliance with CMS rules. In 18 states,
the number of revocations has quadrupled since CMS put the Affordable Care Act
screening and review requirements in place.
Can
plagiarism detection tools catch EHR upcoding?
Software that
verifies the originality of written work is de rigueur in academic
settings. Upon submission of a document, the tool quickly identifies original
author, date, and color-codes portions of the submitted electronic document.
Conceptually, the same software that detects when students submit a
cut-and-paste class paper could also detect “cloning” within an individual’s
electronic health record.
Might academic
detection software create an opportunity for both healthcare organizations and
the government to determine if the record is original?
Importance of detecting cloned
records
On September 24, 2012 the Obama administration provided a warning letter to CEO’s of various hospital and healthcare organizations, signed by the attorney general, Eric H. Holder Jr. and the secretary of health and human services, Kathleen Sebelius. The letter discussed suspicions that the electronic record capabilities of cloning assist some organizations in defrauding the government by way of upcoding evaluation and management (E/M) service codes.
The American Health Information Management
Association (AHIMA), February 13, 2013,testified to the Hearing on Clinical Documentation on the issue
of cloning/copy-paste practices: “Cloned documentation continues to be a
significant problem in EHRs creating unnecessary redundancy and at time
inaccurate information in the EHR. Many organizations have developed policies,
but non-compliance remains an issue.”
Further testimony
by Dougherty indicated some EHR systems are designed to facilitate cloning with
options such as “make me the author” to assume the content of another person’s
entry or “demo recall” to copy and forward vital signs. Default documentation
populating fields on a template allow documentation to be generated indicating
“all systems reviewed and normal” when
all systems may not have been reviewed and results may not have been normal.
RAC audits,
request for records, appeals
The Department of Health and Human Services (HHS) Office of Inspector General, (OIG) issued a report; that correlated an increase in higher-level CPT codes for evaluation and management services with those providers who also used an EHR at their primary practice location. As a direct response to the study, the Centers for Medicare and Medicaid Services, (CMS) alerted the American Medical Association (AMA) to begin conducting audits in 15 states, primarily in Region C, and others in the near future.
Medical
record submissions are required if a Recovery Audit Contractor (RAC), on behalf
of CMS, requests them. The RAC Region B Medical Record Submission Instructions
encourage providers to submit medical records via Electronic Submission of
Medical Data (ESMD); however paper records, faxed, and medical records submitted on a
CD/DVD will be accepted. It is presumed that
cloned entries can easily be detected upon audit when subjected to similarity
detection software. Audits of paper records to detect “cut and paste” features, however, produce voluminous files that
would be more difficult for auditors to challenge. Progression to the EHR, in
combination with advanced software and data analytics, will make audits looking
for cloned records potentially easier in the future.
Cloned records can
be a concern if the RAC auditor’s decision is challenged. Medicare providers
and beneficiaries may appeal certain decisions related to claims for health
care services and items. The Medicare Administrative Appeals Process involves
four levels of appeals, with level one administered by the CMS Medicare
Administrative Contractor, level two administered by CMS Qualified Independent Contractors, level three
administered by Administrative Law Judges (ALJ’s), and level four administered
by the Medicare Appeals Council. In a November 2012 report conducted by OIG, several
ALJs explained that they decide against appellants if the evidence lacks
credibility and they suspect fraud. One ALJ reported he denied claims because
all the medical records look suspiciously similar.
How payment is determined
Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to bill for E/M services furnished in an encounter. ICD-9-CM diagnosis and procedure codes are limited to billing for inpatient E/M services on inpatient claims. Payment based on E/M codes considers patient type, setting of service, and level of service performed. According to CMS 2010 E & M Service Guide three (3) key components — history, examination, and medical decision-making —assist in determining the proper level of service performed and thereby proper payment. Thus, reimbursement is tied to the complexity of the provider’s assessment.
AHIMA members report commonly finding cloned
documentation in the following types of content: history and physical
(particularly social, medical and family history), visit/clinic notes, and
inpatient progress notes, consults, vital signs, and review of systems /
physical exam.) Alignment of increases in cloning detection with criteria that
determines proper level of service performed provides support for government
suspicion that cloning of records appears to align with potential upcoming.
OIG work plan 2013
Since the publication of the September 24, 2012 letter, OIG has identified the “identical documentation across services” and “identify fraud and abuse vulnerabilities in the EHR systems” in its Work Plan for 2013.
From part 1:
Medicare Part A and B; Evaluation and Management Services — Potentially
Inappropriate Payments in 2010, OIG
specifically notes, “We will determine the extent to which CMS made potentially
inappropriate payments for services in 2010 and the consistency of medical
review determinations. We will also review multiple services for the same
providers and beneficiaries to identify electronic health records (EHR)
documentation practices associated with potentially improper payments. Medicare
contractors have noted an increased frequency of medical records with identical
documentation across services.”
Presented
by Electronic Health Records, “We will identify fraud and abuse vulnerabilities in
electronic health records (EHR) systems as articulated in literature and by
experts and determine how certified EHR systems address these From part VII:
Other HHS-Related Reviews; Fraud
Vulnerabilities.”
Current tools to detect fraud and
abuse
HHS and the
Department of Justice published the Health Care Fraud and Abuse Control Program
Annual Report for Fiscal Year 2012 describing several database and data
analytical and mining tools being utilized to uncover fraudulent billing such
as the Fraud Prevention System, One Program Integrity, the Next Generation
Desktop, SAS statistical programming software, CMS Integrated Data Repository
(IDR) and the Command Center.
If the same plagiarism
detection software is not currently used by auditors, we can anticipate that it
will be soon.
ALERTS
The
Centers for Medicare & Medicaid Services (CMS) issues the “Medicare
Quarterly Provider Compliance Newsletter,” an educational product, to help
providers understand the major findings identified by Medicare Administrative
Contractors (MACs), Recovery Auditors, Program Safeguard Contractors, Zone
Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT)
review contractor and other governmental organizations, such as the Office of
Inspector General.
The
following findings are being alerted to providers. Understanding the correct
way to bill will avoid:
Ø DENIALS
Ø AUDITS
Ø
OVERPAYMENTS
Recovery
Audit Finding: Pulmonary Procedures and Evaluation & Management Services
Provider
Types Affected: Physicians and non-physician practitioners
Recovery
Audit Finding: Cataract Removal, Part B Number of Units Incorrectly Billed
Provider Types Affected: Physicians and Non
Physician Practitioners (NPP)
Recovery
Audit Finding: Mohs Surgery Pathology Billed by Separate Provider
Provider
Types Affected: Physicians
Recovery
Audit Finding: Dose versus Units Billed - Bevacizumab (HCPCS J9035) and
Rituximab (HCPCS J9310)
Provider
Types Affected: Hospitals and Physicians
Recovery
Audit Finding: Pre-admission Diagnostic Testing Review
Provider
Types Affected: Inpatient Hospitals
For more information, on any of
the articles posted in this bulletin, please contact Accuchecker
Subject: please indicate ACK BULLETIN INFO
Paul
G. Silverio-Benet
Director
of Operations
HPP
– Accuchecker
Phone:
305-227-2383
Toll
Free: 1-877-938-9311
Fax: 786-364-7356