Knowledge Base Article

CMS continues to provide information to help providers understand and avoid common billing errors and other improper activities identified through claim review programs, such as the Recovery Audit Contractor (RAC) program.

CMS recently released the April 2011 Medicare Quarterly Provider Compliance Newsletter. This edition contains the following information relevant to hospitals:

• Improper Coding of MS-DRG 813 Coagulation Disorders (Inpatient Hospital): Hospitals should ensure that their billing staffs are up to date on the guidelines for coding diagnoses for patients with coagulation disorders, adverse effects of anticoagulants in therapeutic use and coagulation profile.
• HIV – Wrong Diagnosis Code or Wrong Principal Diagnosis Code Billed (Inpatient Hospital): The “ICD-9 CM Official Guidelines for Coding and Reporting” states that, if a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions. (Refer to “Human Immunodeficiency Virus (HIV) Infections,” Section I.C.1.a.2.(a), page 13.) Once a patient has developed an HIV-related illness, the patient should always be assigned the code 042 on every subsequent admission/ encounter. However, this does not mean that 042 must be the principal diagnosis. If the condition responsible for the admission is AIDS related (on the MDC 25 list or tied to AIDS by the physician in documentation), 042 is the appropriate principal diagnosis. If the admission was prompted by an unrelated illness, the principal diagnosis is that illness, and 042 is a secondary diagnosis. (Refer to “Human Immunodeficiency Virus (HIV) Infections,” Section I.C.1.a.2.(b), page 14.)
• Extensive OR Procedure Unrelated to Principal Diagnosis MS-DRGs 981, 982, and 983 (previously DRG 468) (Inpatient Hospital): RAC auditors found many errors in the assignment for MS-DRG 981, MS-DRG 982, and MS-DRG 983 that resulted in overpayments to hospitals.
• Oxaliplatin – Dose vs. Billed Units (Outpatient Hospital): Due to the vast difference for certain time periods in the amounts used (5.0 mg or 0.5mg) to calculate the number of service units being billed, Recovery Auditors found that many hospitals incorrectly calculated the number of service units billed, resulting in overpayment.
  Oxaliplatin HCPCS codes and units are:
• Before July 1, 2003 – J3490 – 0.5 mg
• July 1, 2003 to December 31, 2005 – C9205 – 5 mg
• On and after January 1, 2006 – J9263 – 0.5 mg
• Untimed Codes – Excessive Units (Outpatient Hospital): No matter how long the evaluation or service, providers can bill only one unit of untimed codes for a patient per date of service with some exceptions. Certain services are limited to certain numbers of units per day for physical therapy, occupational therapy and speech-language pathology, separately to control inappropriate billing. Specifically, the HCPCS codes involved are: 90901, 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92609, 92610, 92611, 92612, 92614, 92616, 95833, 95834, 96110, 97001, 97002, 97003, 97004, 97010, 97022, 97026, 97597 and 97598.

The Newsletter also includes information on Inpatient Rehabilitation Facility (IRF) over- and under-payments related to incorrect discharge status codes and OIG findings related to physician billing of Transforaminal Epidural Injection Services. Although this article concerns physician billing, hospitals may find some of the information helpful in their coding and billing of transforaminal injections.

CMS has also added a quick tips feature to the MLN Provider Compliance webpage. A new “fast fact” will be added monthly to this webpage, so be sure to check it often. This month’s fast fact is:

Issue: Physician Orders

Solution: A physician's order is not valid without a legible signature. The physician must authenticate the order. If the order is not signed or authenticated, the physician's intent must be clearly established in the medical records.

The CMS RAC webpage was recently updated with the addition of a downloadable 2011 FFS Newsletter (RAC). This newsletter contains RAC overpayment and underpayment amounts as of March 2011. Providers should note the increase in activity for the last quarter versus the two previous quarters of the National RAC program. Through March 2011, the corrections of the permanent RAC program totals $365.8M. The newsletter also includes the top issues per Recovery Auditor.

Clients of Medical Management Plus can also find the above referenced documents in the Resource section of our website.