Medicare Compliance & Reimbursement

You Can Keep Using DSM-IV and V Under ICD-10

Mental health professionals already consult multiple diagnosis resources (including DSM IV, DSM V and ICD-9) when seeing a patient, so it makes sense that they would be confused about how ICD-10 will impact them. The Centers for Medicare & Medicaid Services (CMS), fortunately, has answers for those practitioners.

“It is expected that clinicians may continue to base their diagnostic decisions on the DSM-IV/DSM-V criteria,” CMS says in a recent FAQ on its website. “In addition, it is still perfectly permissible for providers and others to use the DSM-IV and DSM-V descriptors and diagnostic criteria for other purposes, including medical records, quality assessment, medical review, consultation and patient communications.”

Once the practitioner arrives at a clinical diagnosis and documents it in the patient’s records, then the clinician should seek the appropriate code using an ICD-9 code book for dates of service through Sept. 30, and an ICD-10 manual for dates of service on or after Oct. 1.

Here’s why: “DSM-V contains the standard criteria and definitions of mental disorders now approved by the American Psychiatric Association (APA), and it also contains both ICD-9-CM and ICD-10-CM codes (in parentheses) selected by APA,” CMS says. “Since DSM-IV only contains ICD-9-CM codes, it will cease to be recognized for criteria or coding for services with dates of service of October 1, 2015 or later. Updates for DSM-V criteria and their associated ICD-10-CM codes (identified by APA) will be found at www.dsm5.org.”

Observation Care Will Require Notice to Patients

Observation care can be confusing from a billing standpoint, but it is even more puzzling for patients who think they were admitted to the hospital as inpatients, when in actuality they were simply in the observation unit. That confusion will soon end, however, thanks to a new bill that President Obama signed into law on Aug. 7.

The Notice of Observation, Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals to inform Medicare beneficiaries in observation care that they are outpatients — and not inpatients — and whether they will face cost-sharing implications as a result of that outpatient status. In addition, the notice has to inform patients that they will not be eligible for post-discharge skilled nursing facility services (SNF) since SNF coverage requires a three-day inpatient stay in the hospital.

Although patients cannot typically change to inpatient status after receiving the notice, they can at least make an informed decision of whether or not to pursue post-discharge skilled nursing care, which will cost more due to the lack of an inpatient stay.

Hospital Comes Down on 14 Staffers After HIPAA Violation

Virginia’s Carilion Clinic took action last week after noticing that 14 employees were accessing patient records without any medical reason for doing so. Several of the staff members lost their jobs over the incident, while others were disciplined, the clinic announced.

“In the wake of a recent high profile event in our region, we learned that 14 employees accessed patient medical records without a legitimate patient-care need,” the clinic said in a statement. “Based on the findings of our internal investigation, appropriate actions have been taken with each employee, up to and including termination.”

Although the clinic didn’t disclose what the high profile event was, it’s clear that it is taking the HIPAA law seriously in the wake of the incident. The hospital is now required to report any violations to the government, which can then impose fines and criminal charges if necessary.

What’s in a Name? Potentially Thousands of Dollars in Medicare Reimbursement

That’s the word from Part B MAC NGS Medicare, which revealed in an Aug. 12 email blast that “many providers” are submitting claims in which the beneficiary’s name and Medicare number don’t match, leading to immediate claim denials.

“To prevent claim rejections, please be sure that your office staff members use the beneficiary’s name and Medicare number exactly as it appears on the beneficiary’s Medicare card,” NGS said in the bulletin. If you see a claim rejected for this reason, it is your office’s responsibility to submit a new claim with the right information on it.

Two HHH MACs Team Up on Cost Report Appeals

If Palmetto GBA is your Home Health & Hospice Medicare Administrative Contractor (HHH MAC), you may soon have to deal with National Government Services too. “Palmetto GBA has entered into a subcontracting arrangement with National Government Services to provide cost report appeal services effective August 27, 2015,” the MAC says on its website. “The transition of this workload includes new and existing cost report appeals for both Part A and HHH services.” The change came with new email and physical addresses for cost report matters, Palmetto notes.

Dermatologist Faces 7 Years in Prison

An Illinois dermatologist is heading behind bars for seven years after submitting $3.7 million in claims for pre-cancerous lesion destructions — when his patients didn’t suffer from pre-cancerous lesions.

Some of the doctor’s claims involved the destruction of lesions that weren’t pre-cancerous, while other claims for this service occurred on dates of service when the doctor performed cosmetic procedures such as “lunchtime laser peels,” the Department of Justice (DOJ) said in an Aug. 28 statement. One former patient testified that she underwent repeated laser treatments to lighten her freckles, which the doctor subsequently billed as destroying 491 pre-cancerous lesions on her skin (to the tune of $4,597).

In addition to spending 84 months behind bars, the doctor also has to pay $3.76 million back to the government.

Resource: To read more about the case, visit the Department of Justice’s website at www.justice.gov/usao-ndil/pr/west-suburban-dermatologist-sentenced-7-years-federal-prison-defrauding-medicare. 

Kmart to Pay Millions in False Claims Act Fines

You may feel like regulators are always breathing down your practice’s neck looking for False Claims Act violations, but it might surprise you to learn that even your local discount store chains are facing the pinch from the feds.

On Sept. 1, the DOJ announced that Kmart, a discount chain with 780 in-store pharmacies under its banner, paid $1.4 million to the government to settle allegations that the stores violated the False Claims Act by inducing Medicare beneficiaries to fill prescriptions at Kmart locations by offering them coupons and gas discounts.

“The government alleged that from June 2011 to June 2014, Kmart knowingly and improperly influenced the decisions of Medicare beneficiaries to bring their prescriptions to Kmart pharmacies by permitting the Medicare beneficiaries to use drug manufacturer coupons to reduce or eliminate prescription co-pays that they otherwise would be obligated to pay,” the DOJ said in a Sept. 1 statement. “Federal law prohibits a person from offering beneficiaries of certain federal health programs, such as Medicare, remuneration that is intended to influence the beneficiary’s choice of provider.”

Further, the government alleged that Kmart’s actions prompted Medicare patients to request expensive, brand name drugs rather than cheaper generic drugs, causing the government to increase its Medicare costs even though the more expensive drugs were not medically advantageous to the patients, the DOJ said. “The government also alleged that Kmart improperly encouraged Medicare beneficiaries to bring their prescriptions to Kmart pharmacies by offering them varying levels of discounts on the purchase of gasoline at participating gas stations based on the number of prescriptions that they filled at Kmart pharmacies,” the news release said.

The case was brought to the government’s attention after a Kmart pharmacist reported the potential violations. As a whistleblower, that pharmacist will collect almost $250,000 as his portion of the settlement.

Resource: To read more about the Kmart case, visit www.justice.gov/opa/pr/kmart-corporation-pays-14-millionresolve-false-claims-act-allegations-connection-drug.