Medicare Compliance & Reimbursement

Keep upcoding on your radar, but watch for double-billing errors, too.

If you’re on board with MACRA, then you know that the Quality Payment Program (QPP) is all about the bundle. At the core of value-based, affordable care is coordination, and that’s where the bundled payments come in.

Risky business. As bundling continues to be the preferred means of payment with many new CMS initiatives, the desire to unbundle payments for financial gain abounds. However, this has been a long-standing problem with Medicare providers, who have tried in the past to use two CPT^® codes when one should have been used or who send out numerous bills when a single bill covers the care under one global period.

“Practices should review CMS guidance in the applicable clinical areas to determine where services have been bundled,” says John E. Morrone, Esq, a partner at Frier Levitt Attorneys at Law in Pine Brook, NJ. “The 2017 Physician Fee Schedule guidance provides a useful resource to determine which codes have been aggregated into bundled payments.”

Review the 2017 Medicare Physician Fee Schedule (MPFS) here: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-26668.pdf.

Double trouble. In a duplicate billing situation, the provider bills both CMS and the recipient or private insurer for the same service. Double-billing also occurs when two providers charge for the same service on the same day.

An example of this would be if you sent a patient to an outside lab for a urinalysis, but then your practice and the lab both billed 81000 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) for the service. Only the lab should bill the charge if you didn’t perform the urinalysis.