Ophthalmology and Optometry Coding Alert

Medicaid is also checking your coding prowess.

The Medicare CERT report reveals the most common coding errors among Medicare patients, but that isn’t the only government program checking to ensure you’re reporting your services accurately. A new Medicaid E-Alert indicates that your state Medicaid program could increase its focus on your practice to ensure that you aren’t paid improperly.

Background: In August, CMS issued its “Medicaid Improper Payments E-Alert,” which outlined the 9.8 percent improper payment rate that Medicaid calculated for 2015. Although an error rate below ten percent may not sound too severe, that number represents a startling $29.12 billion.

CMS is intent on ensuring that the number doesn’t rise further next year, so the agency put together a list of contributing factors that prompted the high improper payment rate, along with suggestions on how to fix such problems going forward.

Among the issues that CMS found when auditing Medicaid providers was insufficient documentation. “Medicaid takes the position that if the work is not properly documented, do not bill the services,” the
E-Alert says.

The agency also found issues with incorrect coding and medically unlikely edits (MUEs). “Some services are bundled for billing, like surgery and the follow-up care, and should be billed with one code,” the E-Alert says. “Audit to ensure such bundled services are not billed separately.”

CMS also scrutinized Medicaid claims to find services that could have been covered by another payer. If a patient has insurance with Medicaid as well as with another insurer, the other insurer will always be considered the primary payer. “Medicaid is the payer of last resort,” the E-Alert says.

Example: A patient presents with both Tricare and Medicaid. Knowing that Tricare is always the secondary insurer, you bill Medicaid as the primary payer and then you submit any balance to Tricare.

Reality: This would be accurate if the patient had both private insurance and Tricare, but Medicaid always gets billed last, even if Tricare is the other payer.

Remember: Always verify coverage through the coordination of benefits program before a patient presents to your practice so you know exactly what types of coverage they have. If a patient has another insurer in addition to Medicaid, do not bill Medicaid until the other insurers have already processed the claims.

Resource: To read the complete E-Alert, visit https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/e-alerts-improper-payments.pdf.