Medicare Compliance & Reimbursement

Tip: Incorrect coding will invite RAC scrutiny.

If your doctor is billing for seeing an inpatient in the morning with an initial hospital care code and then again for seeing her in the afternoon with the subsequent care code, you’d better be ready for increased attention from at least one recovery audit contractor (RAC).

Background: When CMS started the RAC program, the agency appointed four RAC contractors to implement it, and those companies must post new issues that CMS has approved them to investigate. These companies include Performant Recovery (Region A), CGI Technologies (Region B), Connolly Consulting Inc. (Region C) and HealthDataInsights (Region D). You can visit each RAC’s website to see where they’re focusing their efforts, but we’ve listed the most recent review areas that impact Part B practices.

Excessive Units of Hospital Visits

When your physician sees a patient more than once in the hospital, he isn’t entitled to bill both initial hospital care (99221-99223) and subsequent hospital care (99231-99233) codes, even if he considers his second visit to be “subsequent” care. Although this may be common knowledge to veteran coders, it is a problem that one RAC will be scrutinizing.

On Feb. 10, CGI Technologies announced that it would be reviewing these cases. “Both initial hospital care and subsequent hospital care codes are ‘per diem’ services and may be reported only once per day by the same physicians of the same specialty from the same group practice,” CGI says in its announcement.

In these situations, the doctor should only report the initial hospital care code (if he is the first person evaluating the patient upon admission) and then start billing the subsequent care codes the next day. CGI appears to be poised to collect from any doctors who collected money for both initial and subsequent hospital care on the same day, and will be reviewing claims with dates of service as far back as Oct. 1, 2010 during its audit.

In black and white: “Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not,” CMS says in Section 30.6.9 of the Medicare Claims Processing Manual. “The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.”

This audit applies to practices in Minnesota, Wisconsin, Indiana, Ohio and Kentucky.

PTA Under Scrutiny

If your cardiologist seems to schedule an excessive number of percutaneous transluminal angioplasty (PTA) procedures, now is the time to ensure she has documentation supporting the medical necessity of the surgeries, because one RAC is watching carefully.

On Feb. 10, Connolly Consulting announced that it would be reviewing medical documentation “to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.” This audit will apply to all claims with dates of service within the last three years.

In black and white: CMS covers PTA on a national basis for the following conditions, according to the agency’s National Coverage Decision 100-3 (available at www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=201).

• Treatment of atherosclerotic obstructive lesions; 
• Concurrent with carotid stent placement in FDA-approved Category B investigational device exemption clinical trials;
• Concurrent with carotid stent placement in FDA-approved post approval studies;
• Concurrent with carotid stent placement in patients at high risk for carotid endarterectomy.

Your local MAC might have different coverage criteria, so be sure and check your local policies before billing PTA services. This audit applies to all of Region C, which includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia.