Medicare Compliance & Reimbursement

Mark Your Calendars: CMS Sets March 3-March 7 As ICD-10 Testing Week

If you worry about whether your claims will appropriately process on Oct. 1, 2014, fret no more. You’ll get to test out your ICD-10 coding skills this spring with a dry run that the Centers for Medicare & Medicaid Services (CMS) plans to offer practices who want to submit sample ICD-10 claims, CMS announced in MLN Matters article MM8465, published on Nov. 1.

During the week of March 3 through March 7, 2014, your MAC will allow you to send in your test claims that include ICD-10 codes. If you have difficulty processing the claims, you’ll be able to contact the help desk to figure out what went wrong. In addition, you will get electronic acknowledgement of your test claims that will tell you whether they were accepted or rejected.

After the testing period ends, CMS will share information about the percentage of test claims that were accepted versus rejected, and will offer additional information about lessons learned during the testing period.

To read more about the ICD-10 test dates, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8465.pdf.

Prominent Cardiologist Faces Over 6 Years in Prison

If your physician runs the same test on every patient who walks in the door, it’s time to explain to the doctor that this is not compliant behavior. Such a warning probably could have saved a New Jersey cardiologist from prison, but it’s too late in his case.

The cardiologist, who is the owner of two large companies in N.J. and N.Y., not only faces 78 months in prison, but must pay $19 million in restitution for conspiring in a multimillion dollar health care fraud scheme, the Department of Justice reported on Nov. 20.

“Over the course of the conspiracy, the doctor ordered and performed essentially the same battery of diagnostic tests for nearly all the patients he treated, regardless of their symptoms,” the DOJ says in its press release. The physician also falsified patient charts to give them symptoms and diagnoses that justified unnecessary treatments of external counter pulsation.

The physician collected more than $15 million for these treatments from Medicare and Medicaid for these services, in addition to other fraudulent issues that he admitted.

To read more about this case, visit www.justice.gov/usao/nj/Press/files/atz, Jose Sentencing PR.html.

CMS Sets Jan. 6 as PECOS Ordering/Referring Edit Implementation Date

If your practice put phase two of the Medicare ordering and referring edits on the back burner since CMS has delayed it so many times, you may want to turn your attention back to the subject. CMS announced on Nov. 6 that the edits will kick in on Jan. 6, 2014.

“Effective January 6, 2014, CMS will turn on the edits to deny Part B clinical laboratory and imaging, DME, and Part A HHA claims that fail the ordering/referring provider edits,” CMS says in MLN Matters article SE1305. “Claims submitted identifying an ordering/referring provider and the required matching NPI is missing will be rejected.”

For those of you keeping score at home, it has now been over three years that CMS has delayed phase two of the ordering/referring edits. The agency was initially shooting for a Jan. 4, 2010 implementation date, but pushed it back indefinitely before that date. Then in July of 2012, CMS announced the PECOS denials would begin “soon,” followed by a firm date of May 1, 2013 earlier this year. However, just before May 1, CMS pushed it back again, and now January is the updated date.

To read the complete article on the new phase two edit date, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf.

Medicare Cracks Down On Inpatient Billing For Hospital Patients

CMS is taking the next step to turn up the heat on hospices that it views as shirking their bundling responsibilities.

Under a new Change Request, in April Medicare will “deny an inpatient hospital claim when the principal diagnosis on the inpatient claim matches one of the hospice diagnosis codes,” CMS says in Nov. 7 CR 8273. “Services related to a hospice terminal diagnosis provided during a hospice period are included in the hospice payment and are not paid separately. An inpatient hospital claim will be denied when providers bill with a condition code 07 on an inpatient claim and the principal diagnosis on the inpatient claim is found to match one of the hospice diagnosis codes.”

Hospices can say thanks to Recovery Audit Contractors for the new edit. RAC data “identified inpatient hospital claims where the principal diagnosis listed was one of the patient’s listed hospice terminal diagnoses during the hospice period, yet providers were billing the principal diagnosis with a condition code 07,” CMS notes in the CR. “The payments associated with these claims are considered overpayments because [CMS] does not pay separately for an inpatient hospital stay when a hospice terminal diagnosis is listed as a principal diagnosis.”

CMS does acknowledge that services won’t always be related to terminal illness in these cases, however. “In the limited instances (e.g., as the result of an appeal or reopening) where payment is appropriate, the A/B MAC shall have the capability to override the edit,” the agency instructs its MACs in the CR.

Watch out: The CR’s implementation date is April 7, but “we believe the CR instructs MACs to retroactively review hospital claims with dates of service within 3 years of the implementation date,” warns the National Association for Home Care & Hospice. “Therefore, MACs are expected to recoup the overpayments from the billing hospital for any hospital claims that match the edit criteria.”

That will lead hospitals to come knocking on the hospice’s door for reimbursement from three years ago, observers say.

The CR is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1312OTN.pdf.