Knowledge Base Article

CMS’s Medicare Learning Network (MLN) offers a number of articles, booklets, podcasts and other educational materials to educate providers concerning Medicare requirements. MMP encourages providers to utilize these resources but also to be aware of the topics addressed. MLN educates concerning issues that Medicare contractors or other government entities have found to be at-risk areas for non-compliance. So the benefit of the MLN products is two-fold: identification of issues that you may need to consider for internal review and guidance on achieving compliance.

For example, MLN recently released an article (SE1401) on overpayments identified by Recovery Auditors when the wrong admission source is reported for a patient transferred from an acute care stay to a distinct-part psychiatric unit in the same facility. Inpatient psych facilities receive additional payment for the first day of admission if the facility has a qualifying emergency department. This payment is not appropriate if the patient is transferred from acute care to psych within the same facility. In order to prevent inappropriate overpayment, the Point of Origin for Admission or Visit Code "D" (formerly the Source of Admission Code) must be used when a patient is discharged from an acute-care stay in a hospital and transferred to the same hospital’s inpatient psychiatric Distinct Part Unit (DPU). This issue has also been identified on several OIG Hospital Compliance Audits.

This quarter’s Provider Compliance Newsletter did not address any inpatient hospital issues (perhaps due to the change in Medicare admission guidelines and the mandated delay in contractor reviews of medical necessity of admissions). Two articles did address outpatient hospital issues related to dose versus units billed for the drugs zolendronic acid (Zometa) and Adenosine. Correct billing of drug units is a long-standing compliance challenge for hospitals. Drugs units billed are based on the dosage administered and the HCPCS code description of the drug. For example, as noted in the Compliance newsletter, adenosine HCPCS code J0152 was defined as 30 mg. So an injection of 30 mg of Adenosine was properly billed as 1 unit of J0152.

Adding to the challenge of billing drug units correctly are changes in codes and/or descriptions. For 2014, Adenosine is now billed with HCPCS code J0151 which is per 1 mg – in 2014 a 30 mg injection of Adenosine will be billed as 30 units of J0151. And although the units describing Zometa have not changed, there have been 3 different codes within the past year (J3487 prior to July 1, 2013; Q2051 from July 1 through December 31, 2013; and J3489 effective January 1, 2014). In order to submit Medicare claims with compliant drug charges, hospitals must:

• have someone diligently watch for Medicare updates to drug codes and descriptions,
• verify their charge description master drug codes and “multiplier” units are correct and updated as needed, and
• ensure correct “translation” from the pharmacy module to the billing module.

One other MLN product that might be of interest to hospitals is the Discharge Planning booklet. Experienced case managers, discharge planners, and social workers are likely familiar with the information in the booklet, but it offers a good overview and links to the relevant Medicare manuals. It would be an excellent resource for new staff members dealing with discharge planning.

Providers should take advantage of the educational products provided by CMS and their area MACs. The information is good and the topics are important. And in the case of errors related to these topics, a hospital wouldn’t have much luck arguing they didn’t know the rules.