Medicare Compliance & Reimbursement

A hospital's misunderstanding of outpatient prospective payment system billing rules has caught the attention of the HHS Office of Inspector General.

As Mercy Hospital was transitioning to OPPS, it mistakenly believed that only one surgical procedure could be claimed each time an operating room was used. As a result, when multiple procedures were performed during a single OR session, the hospital claimed ambulatory payment classification reimbursement for just one of the procedures.

That meant that Mercy received far less than it deserved in APC payments - but too much in subsequent outlier payments, the OIG maintains in "Review of Outlier Payments Made to Mercy Hospital Under the OPPS for the Period August 1, 2000 through June 30, 2001" (A-01-02-00518).

Tip: What the hospital should have done, the OIG points out, is separately identify each surgical procedure with its specific HCPCS code on the claim.

In its review, the OIG also identified billing errors for drugs and biologicals, a problem that has also emerged in agency reviews of other hospitals' outlier payments.

To see the report, go to http://oig.hhs.gov/oas/reports/region1/10200518.pdf.

Lesson Learned: Hospitals should ensure that their billing staff know the rules for submitting claims for multiple surgical procedures performed in a single OR session.