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Medicare Compliance & Reimbursement

Industry Note:

CMS Debuts New 'Date of Death' Code

Published on Tue May 15, 2012

CMS Debuts New 'Date of Death' Code

When a patient passes away while in your physician's care, you may be familiar with adding the death-related discharge codes to his claims -- but now you have another code to tack on to those.

CMS introduced occurrence code 55 last week, which you must report along with a patient's date of death when the patient's discharge status is 20 (Expired), 40 (Expired at home), 41 (Expired in a medical facility), or 42 (Expired -- place unknown), according to MLN Matters article MM7792.

Effective Oct. 1, you must include code 55 with these discharge indicators, or you may face denials.

To read more about this new date of death code, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7792.pdf.

State Comptroller Audits Show UHC, Empire Were Overpaid $11 Million

Two state comptroller audits released in April 2012 show that Empire Blue Cross Blue Shield (BCBS) and United Healthcare (UHC) were overpaid by a combined total of $11 million for healthcare services, some of which were never even performed.

Both payers process claims for New York's government employee health plan, known as the Empire Plan. The audits suggest that neither payer appropriately or effectively monitored provider claims. There were errors in 111 (57 percent) of the 194 claims in the Empire review sample, resulting in a net overpayment of $387,772 for the sample, according to the audit.

In the UHC audit report, the reviewers stated: "For 27 (12.6 percent) of the 214 claims we tested, a significant and separately identifiable E/M service was not provided. On one claim, for example, United paid a provider $561 for a lesion removal and another $204 for a purported E/M service. However, there was no indication in the medical records that a significant and separately identifiable E/M service was, in fact, provided. Thus, the provider should not have billed (and United should not have paid) the additional $204 for the E/M service."

"While most New Yorkers are watching their spending, Blue Cross Blue Shield and United HealthCare are not monitoring bills and are letting the state overpay health providers," said NY comptroller Tom DiNapoli. "An error rate showing that nearly 6 of every 10 claims are billed incorrectly is simply unacceptable and cannot continue."

You can review the Empire audit at www.osc.state.ny.us/audits/allaudits/093012/10s74.pdf.

CMS Fraud Program Crunches Data At Big Brother Levels

The Medicare program may have a closer eye on you than you think. CMS "has implemented a major data-gathering, data-mining and data-matching program," points out law firm Duane Morris in a client alert. "While the implementation of this program appears to have been virtually unnoticed, providers should be aware of the nature and volume of information that CMS has been gathering about them and how this information is being, and can be, used," the firm warns.

CMS is transitioning away from pay-and-chase recoveries and toward more proactive prepayment screening, Morris notes. The agency is using claims screening tools to pick up aberrant billing patterns, then passing that information along to the Zone Program Integrity Contractors (ZPICs) or law enforcement.

Bottom line: "Providers should assume that every claim they submit will be subjected to prepayment screening, which will provide CMS with a vast amount of information about every provider that can be cross-checked, messaged, shared and stored for future use," the firm stresses.

A new MLN Matters article about CMS's National Fraud Prevention Program, including information on automated provider enrollment screening and site visits, is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1211.pdf.

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