Medicare Compliance & Reimbursement

With Election Over, All Eyes Turn to Medicare Cuts With the election over, providers' eyes are turning to Washington, D.C. to see how lawmakers resolve the so-called "fiscal cliff" budget problems, which include the two percent across-the-board sequestration cuts set to hit Medicare providers' payment rates in early 2013. Certain healthcare provider groups fear becoming targets for lawmakers to raise funds to head off the cuts in other areas. For example, hospital industry reps are already lobbying very publicly against another round of cuts to their rates. Physicians also will be seeking funding from Congress, since they face a newly finalized 2013 Medicare Physician Fee Schedule that includes a 26.5 percent cut. "In the absence of Congressional action, an overall reduction of 26.5 percent will be imposed ... on or after January 1, 2013," says the fee schedule slated for publication in the Nov. 16 Federal Register .   How health care matters get handled in Congress may change, now that a veteran politician with a healthcare focus has been defeated. Eighty-year-old House Ways and Means Health Subcommittee chair Pete Stark (D-Calif.) was defeated by a 31-year-old challenger from his own party. Stark, for whom the "Stark Law" is named, is leaving after 40 years in Congress. Take Note of Errors in CPT^® 2013, AMA Instructs Get out your favorite red pen to delete and add instructions to your new book. If you're scratching your head about some of the items that you feel the new CPT ® manual is missing -- or including -- you aren't alone. Check out these changes you need to make to the 2013 CPT® manual, which you most likely just received within the past week or two. For example, in the CPT ® section regarding respiratory endoscopic surgery to the trachea and bronchi, a current parenthetical note states, "For endoscopy procedures, code appropriate endoscopy of each anatomic site examined. Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same physician. Codes 31622-31649, 31651, 31660, 31661 include fluoroscopic guidance, when performed." The code list at the end should be changed to the new range of 31622-31651, 31660, and 31661, which include fluoroscopic guidance. In addition, you'll want to correct the bronchoscopy codes listed with the illustration of a bronchoscopy. Currently, the CPT ® manual directs you to 31622-31646, but in reality that should say 31622-31651. You'll also want to tidy up the parenthetical language in CPT ®'s Cardiography section, which currently says, "For electrocardiogram, 64 leads or greater, with graphic presentation and analysis, use 93799." However, you should strike 93799 from the book and replace it with codes 0178T-0180T. To read the complete list of errata, visit the AMA Web site at www.ama-assn.org/resources/doc/cpt/cpt-corrections-errata.pdf. Prepare Now For Supply Concerns From Diabetic Patients Your diabetic patients may have more difficulty obtaining their test strips following an OIG crackdown on supplier billing for the items. Background: "Under Round 1 of CMS's Competitive Bidding Program, implemented in January 2011, non-mail order [diabetes test strips] in Competitive Bidding Areas (CBAs) are reimbursed at a rate more than double that of mail order DTS," the HHS Office of Inspector General explains in a new report. "This price difference provides a financial incentive for suppliers to bill for non-mail order rather than mail order DTS." "Claims in CBAs for the more expensive, non-mail order DTS increased by 33 percent from 2010 to 2011, while claims for the less expensive, mail order DTS decreased by 71 percent," the OIG reports. "Further, for 20 percent of beneficiaries in our review, suppliers improperly billed Medicare for the more expensive, non-mail order DTS in 2011, but beneficiaries reported having instead received the less expensive, mail order DTS." The report is online at https://oig.hhs.gov/oei/reports/oei-04-11-00760.pdf. HIPPS Validation Underway For Post Acute Providers Get ready for another claims processing hurdle to block your way to Medicare payment. The Centers for Medicare & Medicaid Services is implementing edits to validate HIPPS codes against assessment data for three post-acute providers: home health agencies, inpatient rehab facilities, and skilled nursing facilities. First up are IRFs, whose validation edits went into place Oct. 1. CMS plans to implement HHA and SNF edits on future dates "to be determined," the agency notes in MLN Matters Article No. MM7760. Why? "Currently, the [Fiscal Intermediary Shared System] does not have access to the assessment databases," CMS notes in the article. "This inability to validate the submitted Health Insurance Prospective Payment System (HIPPS) code(s) against the associated assessment creates significant payment vulnerability for the Medicare program." How it will work: If the HIPPS codes on the claim and in the QIES OASIS assessment database agree, Medicare will release the claim for processing, CMS explains. If not, the MAC will use the assessment to generate a new HIPPS code. If there is no corresponding assessment file in the database, the system will return the claim to provider, CMS says in revised Transmittal No. 2495 (CR 7760). "Although a date has not yet been determined for implementing this process for home health claims, agencies should be make certain to take necessary steps to be prepared for this," warns the National Association for Home Care & Hospice. Tip: "Agencies that use outside vendors rather than HAVEN to generate HIPPS codes should verify the HIPPS codes that their software generates against HAVEN prior to submitting claims," NAHC advises. Resources: The transmittal is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2495CP.pdf and the MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7760.pdf. MAC Targets Claims With 5-7 Visits Make sure your documentation for episodes that barely exceed the LUPA threshold will stand up to scrutiny, or you could face steep denials. In a recent review of home health agency claims containing five to seven visits, Home Health & Hospice Medicare Administrative Contractor NHIC denied 68 percent of claims, the MAC says on its website. NHIC reviewers denied 33 claims because documentation did not support the skilled nursing services as being medically necessary, the contractor says. "A frequent cause of denials in this situation is when the documentation did not show the need for observation and assessment of the patient's condition," the MAC details. NHIC denied seven claims because it didn't receive documentation timely, the MAC adds.