Medicare Compliance & Reimbursement

Although it was over a month ago that Congress voted to extend the ICD-10 implementation date, CMS has been strangely mum on the topic, which was puzzling to many providers who were eager to find out when they’ll have to start using ICD-10 codes. However, a new proposed rule seems to suggest that the implementation date was pushed back by exactly one year.

As of press time, CMS has not made an official statement about the new implementation date, but the 2015 Inpatient Prospective Payment System Proposed Rule cites Oct. 1, 2015 as the new ICD-10 implementation date in several different spots. “The ICD-10-CM/PCS transition is scheduled to take place on October 1, 2015,” the proposed rule states on page 648. In addition, the document refers to the 2015 date in two other instances as well.

Although CMS has not yet updated its website to reflect this new date announcement, it’s likely that the agency will do so soon to align with the IPPS proposal. Keep an eye on these pages for more as the ICD-10 date is confirmed by CMS officials in the coming days.

This Hospital Faces A Steep Fine For Giving One Cardiology Group Preferential Treatment

Although most physicians know that they can’t collect cash for hospital referrals, one New Jersey cardiology group seems to have violated the golden rule — and the hospital will pay dearly for that infraction.

A hospital in New Jersey paid $435,640 last week to settle allegations that it violated the False Claims Act by paying rental fees that were above fair market value to a cardiology group that referred a “significant” number of patients to the facility.

“Making inflated rental payments to induce referrals is no better than slipping a doctor an envelope stuffed with cash,” U.S. Attorney Paul J. Fishman said in an April 30 statement. “Kickback arrangements undermine the physician-patient relationship and can lead to unnecessary treatment and higher costs. There is no room in our healthcare system for hospitals that abuse federal health care programs to boost their bottom line.”

To read the complete report, visit www.justice.gov/usao/nj/Press/files/Somerset Medical Center Settlement PR.html. 

Home Health Agencies: Ease Your PECOS Edit Appeals Burden With Reopenings

If you’re filing a redetermination when your claims get denied for physician PECOS edits, you’re wasting time and money. So say two Home Health & Hospice Medicare Administrative Contractors in new messages to providers.

In fact, for CGS “the only recourse to receive Medicare payment for this type of denial is to request a reopening,” the MAC stresses in its email message to agencies. “Do not resubmit a new claim or submit a redetermination request.”

Palmetto GBA merely says that home health agencies “may qualify for an appeal using the Clerical Error Reopening process, rather than the redetermination process.” Claims denied due to the ordering/referring edits will display reason code 37236 or 37237, the MACs explain.

Hold up: There’s no point in submitting your reopening request if the physician hasn’t updated her PECOS record, the MACs warn — it will only continue to deny. “The physician must work with their Part B Medicare Administrative Contractor to update their PECOS record,” they say.

You’re out of luck if the physician’s enrollment date was after the dates of service on your claim though. Medicare will not pay such claims, Palmetto says.

Tip: “Remember that the NPI being reported in the Attending Physician field of the claim is only for the NPI of the physician that signed the Plan of Care,” Palmetto adds.