The Devil’s in the Details: Read Medicare Compliance Newsletters Carefully

on Monday, 05 November 2012. All News Items | Coding | Billing

CMS’s Medicare Learning Network publishes quarterly Medicare Compliance Newsletters to address the findings from reviews by Medicare contractors such as MACs, RAs (formerly RACs), ZPICs, CERT and the OIG. A cursory look at the October 2012 newsletter might lead you to believe it is the same old issues with the same old information. But a more thorough reading of the details reveals education and guidance on coding / billing issues and examples of services provided in an inappropriate level of care. And of course the usual information is there also – but in these days of seemingly never-ending recoupment, one more reminder doesn’t hurt.

Coding Issues

Inappropriate secondary diagnosis with major joint replacements that resulted in inappropriate DRG assignment:

  • “Moderate protein nutrition” should only be assigned code 263.0, Malnutrition of moderate degree, because this code category includes protein-calorie malnutrition. Code 260, Kwashiorkor, is not appropriate since this condition was not specifically documented. (Coding Clinic: Third Quarter, 2009)
  • Code 416.2 was created in October 2009 to describe chronic pulmonary embolism to distinguish these from acute pulmonary emboli. Use this code if the patient did not have an acute PE during the current admission, instead of reporting code 415.19. (Coding Clinic, Fourth Quarter, 2009)

Sequencing errors related to the principal diagnosis with cardiac procedures that resulted in inappropriate DRG assignment.

  • Code acute myocardial infarction (410.xx) as the principal diagnosis rather than CAD (414.01) for patients who present with an acute MI and are successfully treated with angioplasty. (Coding Clinic, 4th Quarter 2005 and Coding Clinic, 2nd Quarter, 2001)

Billing Issues

Outpatient within Inpatient Stay

  • A separate claim for laboratory services by the same hospital during the time frame of an inpatient admission.
  • A separate claim by another hospital for ERCP services during an inpatient admission. If an outside entity provides services to an inpatient, those services are part of the inpatient admission. The inpatient hospital should make arrangements with the outside entity to ensure that a separate outpatient claim is not submitted to Medicare.

Inappropriate Hospital Admissions

Respiratory Conditions

  • Patient with mild COPD 2 and costochondritis who presented with chest pain and successfully treated with IV ketorolac; discharged next day. Per Medicare reviewers, services should have been provided at outpatient level of care.
  • Patient with wheezing and hypoxemia post EGD; successfully treated with IV Solu-Medrol and IV Protonix and discharged home the next day. Per Medicare reviewers, services should have been provided at outpatient level of care.

DRG 581, Other Skin, Subcutaneous Tissue and Breast Procedures

  • Two examples of uncomplicated mastectomies, discharged home the next day. Per Medicare reviewers, services should have been provided at outpatient level of care.

Please read the October 2012 Medicare Quarterly Compliance Newsletter to see the complete examples and other helpful information.

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