Medicare Compliance & Reimbursement

It may be wise to beef up your documentation for services your hospice patients receive that aren't related to the terminal diagnosis. Under Medicare payment rules, the hospice per diem payment rate does not have to cover services that are unrelated to the terminal diagnosis for the patient.

But regional CMS offices are seeing "misunderstandings" about what fits into that category, CMS's Lori Anderson said at the National Association for Home Care & Hospice's March on Washington conference March 28.

"A terminal diagnosis is not one ICD-9 code," Anderson emphasized to attendees. At the end of life, "almost everything" is related to the terminal condition. "It's the exception and not the norm if it's not related," she said.

The regional offices (ROs) are seeing cases where hospices classify anything not related to one ICD-9 code -- the patient's primary diagnosis -- as unrelated, and thus not subject to payment coverage by the hospice rate, Anderson explained.

The ROs and OIG are seeing this problem among nursing home patients, in particular, Anderson said. "It's a good thing that nursing home patients get hospice," she asserted. But payment must follow the Medicare rules. One hospice provider insisted that the policy is a departure from CMS's previous guidance. But, Anderson maintained that the policy is not a departure. RACs hauled in $162 million in overpayments in first quarter of 2011. You may not be in the sights of your local recovery audit contractor (RAC), but that doesn't mean the RACs aren't hard at work. A new CMS report reveals the results of RACs nationwide and the numbers are surprising.

During fiscal year 2010 (Oct. 2009 through Sept. 2010), RACs collected $75.4 million from practices that were overpaid by their Medicare contractors -- but that number pales in comparison to the amount the RACs collected just in the first three months of 2011. Between January and March of this year, the RACs collected $162 million in overpayments.

The good news: Despite their reputation as "bounty hunters," the RACs do appear to be returning money to practices that were underpaid. During the first quarter of 2011, the RACs returned $22.6 million to practices. All told, they found $184.6 million in incorrect Medicare payments during the first three months of this year.

Example: The CMS report reveals several of the overpayment errors that the RACs discovered. For instance, Region A RAC (Diversified Collection Services) found that practices were improperly adding the number of ventilation hours that practitioners billed, resulting in higher reimbursement. The RAC reminds practices that "ventilation hours begin with the intubation of the patient (or time of admittance if the patient is admitted while on mechanical ventilation) and continue until the endotracheal tube is removed, the patient is discharged/transferred, or the ventilation is discontinued after a weaning period."

To read the complete CMS report, visit www.cms.gov/RAC/Downloads/FFSNewsletter.pdf.

CMS paid out over $380 million in PQRS and ePrescribing incentives in 2009 bringing hope for practices. Medical practices raked in millions in 2009, thanks to incentives from the Physician Quality Reporting System (PQRS) and ePrescribing Incentive Program, a new report indicates.

On April 19, CMS released its "2009 Physician Quality Reporting System and ePrescribing Experience Report," which shows that 119,804 physicians and other eligible professionals collected over $234 million in 2009 via the PQRS. Under the ePrescribing Incentive Program, CMS paid $148 million to 48,354 physicians and eligible professionals during the same period, which was the first year for e-prescribing bonuses.

Most of the bonuses were paid out to practitioners in ambulatory settings, such as physician offices, the report indicates. "Most beneficiaries get their care in the physician office; however, this is the care setting for which we have the least amount of data about quality of that care," said CMS Administrator Donald Berwick in a statement. The PQRS program and the ePrescribing incentive "help bridge the knowledge gap so we can better understand the care millions of patients receive from physicians and other care providers each day," he said.

To read the complete report, visit www.cms.gov/PQRS/.