Inpatient Facility Coding & Compliance Alert

Plus: Laparoscopic hernia repairs are under the microscope.

Is it a practice in your facility to bill inpatient codes for SNF (skilled nursing facility) assessments? If so, you could land under the audit radar of RACs.

Many providers are so accustomed to either reporting outpatient or inpatient E/M codes that they don’t realize other such codes exist for encounters that fall outside of those two categories. This may have been the cause of a recent audit finding revealing that many practitioners are billing inpatient codes when performing skilled nursing facility (SNF) evaluations.

“Improper coding for SNF services has been a longstanding problem, although one that is easily remedied by proper coding and reporting from the physicians and practitioners,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA.

According to the January 2016 Medicare Quarterly Provider Compliance Newsletter, RACs are reporting to CMS that they have seen this issue multiple times.

“The Recovery Auditors are finding that physicians and non-physician practitioners (NPPs) are reporting incorrect codes for E/M services provided to SNF Medicare patients,” CMS says in the 26-page document. “CMS reminds physicians and NPPs that they must not use CPT^® codes 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …), or the subsequent hospital care codes, 99231-99233, or hospital discharge codes 99238 and 99239 to bill for E/M services supplied to SNF patients.”

Instead, you’ll report a code from the 99304-99306 (Initial nursing facility care, per day, for the evaluation and management of a patient …) range for initial nursing facility care, or 99307-99310 (Subsequent nursing facility care, per day, for the evaluation and management of a patient …) for established nursing facility care. Keep in mind that you can report a hospital discharge code (99238-99239, Hospital discharge day management …) in addition to a nursing facility admission service when applicable, but just because the patient happened to be in the hospital earlier in the day doesn’t mean you should report hospital codes even for the SNF service.

Step up Hernia Documentation

Also in the latest compliance report were CMS’s concerns about how to appropriately report laparoscopic hernia repairs (49650 and 49652), since many of these claims were billed incorrectly.

Insufficient documentation: “The vast majority of the improper payments were due to insufficient documentation,” CMS said in the report. For instance, the medical reports were missing items such as a signed operative report, the correct date of service, or a signature log/attestation for an illegible signature.

Other issues that auditors found involved claims for hernia services that weren’t performed and those that included mesh placement when the documentation didn’t include any references to mesh.

If your surgeons are making these types of errors, it’s time to sit down and conduct a hernia coding training session with them. Considering that 49650 (Laparoscopy, surgical; repair initial inguinal hernia) pays over $443 and 49652 (Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible ) reimburses about $772, your practice can’t afford to return the money you’ve earned for these claims simply because your physician didn’t document properly. Explain to the doctors what the notes must include and the nuances that differentiate one level of repair from the others.

 “Hernias are an issue because of the relatively high frequency of these procedures,” says Abbey. Also, note that with the regional MACs, the coding and billing of the surgeons (1500) can be compared to the hospitals billing and coding (UB-04). Thus, questions concerning consistency of coding and the reporting of mesh as an implantable item can be easily examined.”

Lessons learned: “Both of these situations, SNF E/M and hernia repairs, offer the opportunity to improve documentation that will in turn result in compliant filing of claims,” explains Abbey. “Coding staff should work with physicians to assure that complete documentation is being provided, place of service is accurately reported, and that operative reports are signed, dated, and the time of signature is indicated. This is a best practices issue and physicians should become accustomed to doing so.”

Resource: To read the entire compliance newsletter, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909199.pdf.