Medicare Compliance & Reimbursement

Dx Coding Rules Change: Don’t Get Caught Asleep at the Wheel

As most coders are aware, the ICD-10 diagnosis coding system makes its debut on Oct. 1, 2014, and you’ll have to be ready to make the transition swiftly. CMS will not allow a grace period after that date, nor will they accept both ICD-9 and ICD-10 codes on your claims.

To help with the transition that you’ll face next year, CMS revised MLN Matters article MM7492 recently to remind practices of the vast billing changes that will take place next year. The following tips from the article will help you prepare:

Claims with both ICD-9 and ICD-10 claims submitted for dates of service on after Oct. 1, 2014 will be returned as unprocessable and you’ll receive no reimbursement for them. Report only the ICD-10 code(s) after Oct. 1, 2014.

Certain services that span from pre-Oct 1, 2014 through after that date will have to be split into separate claims. For instance, any outpatient hospital services that span the implementation date will be billed as two claims — the first will be listed with the dates of service through Sept. 30, 2014 (using ICD-9 codes) and the second will be listed with dates of service Oct. 1, 2014 and later (using ICD-10 codes). However, anesthesia claims that begin on Sept. 30, 2014 and end on Oct. 1, 2014 will be billed using Sept. 30 as both the "from" and "through" date, and should be billed using ICD-9 codes, the article says.

Don’t try to get a jump start on billing with ICD-10 codes, since CMS will reject any ICD-10 submission for dates of service prior to Oct. 1, 2014.

Keep in mind: The ICD-10 implementation date in the MLN Matters article was not updated and appears incorrectly as October 1, 2013, but the true implementation date is still Oct. 1, 2014, explains MAC CGS on its website. Watch for a corrected version of the article to appear soon.

To read the complete article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles.

OIG Asks Government for An Additional $82 Million for CMS Oversight

If it feels like the OIG uses more resources to go after inappropriately-billed and paid Medicare claims every year, that’s because it’s true. After raking in record recoupments in 2012, the OIG wants to step up its efforts even further, requesting $320 million in FY 2014 for overseeing Medicare and Medicaid — this represents over $82 million more than the 2012 amount.

The OIG intends to use the extra dollars for fraud prevention as well as "identifying questionable billings and reducing improper payments" in the Medicare and Medicaid programs.

To read the complete 2014 OIG budget proposal, visit oig.hhs.gov/reports-and-publications/archives/budget/files.

Home Health Improvement Standard One Step Closer To Getting The Boot

Medicare contractors that have used the so-called "improvement standard" to deny home health and other post-acute claims are on notice to stop, thanks to a new fact sheet issued by the Centers for Medicare & Medicaid Services (CMS).

"The Medicare statute and regulations have never supported the imposition of an ‘Improvement Standard’ rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition," CMS says in the sheet. "A beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage."

Bottom line: "Coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves," CMS says.

CMS has issued the fact sheet after settling a lawsuit over the issue, Jimmo v. Sebelius. The sheet doesn’t expand coverage, but merely clarifies existing coverage policies, the agency maintains.

Spreading the word: CMS plans to issue updated program manual language, new transmittals and MLN Matters articles and other materials, it says. CMS will complete the manual revisions and educational campaign by next January.

CMS also will review a random sample of HHA, skilled nursing facility, and outpatient therapy coverage decisions "to determine overall trends and identify any problems," it says. It also will review "individual claims determinations that may not have been made in accordance with the principles set forth in the settlement agreement."

The fact sheet is at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf.