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Medicare Quarterly Compliance Newsletter - Condition Code B4, Signed Orders, and Frequency Limits

Published on 

Friday, October 23, 2015

 | CERT 

So much of healthcare is a team effort – doctors, nurses, and ancillary services working together to care for patients; billing, coding and case management working together to ensure appropriate inpatient billing; ancillary departments and compliance working together to ensure proper documentation to support billing; and many other incidences of coordination within a hospital that are too numerous to name. The October Medicare Quarterly Provider Compliance Newsletter includes a few compliance issues related to hospitals that definitely require a team effort: one for inpatient billing and a couple regarding outpatient laboratory services.

The inpatient item addresses same-day readmissions. When a Medicare beneficiary is readmitted on the day of discharge to the same acute care PPS hospital, and the reason for the readmission is related to the condition treated in the prior admission, the hospital must combine the original and subsequent stay onto a single inpatient claim. Medicare does not specifically define “related” other than to say “for symptoms related to, or for evaluation and management of, the prior stay’s medical condition” so this can be a judgment call for the hospital. If the claims are combined, coding of diagnoses and procedures must encompass the entire “combined” stay which began when the patient was first admitted and ends with the discharge from the readmission. Present on Admission (POA) indicators are based on the original admission date since this is “one” admission for Medicare.

If the same-day readmission is not related to the prior inpatient admission, the hospital should submit separate inpatient claims and report Condition Code B4 on the second admission. Make sure your documentation clearly supports an unrelated admission because Medicare may request your records for review to support a separate same-day readmission. If hospitals fail to add the condition code B4 to a second unrelated admission, Medicare payment may be at risk of recoupment for automated reviews by Recovery Auditors or other Medicare reviewers.

Hospitals need to have a system in place to address same-day readmissions to:

  • Determine if the readmission is related to the prior admission or not. This is a clinical decision and you need to involve clinical staff, such as Case Management, in this review.
  • Appropriately code the entire episode for related combined admissions. Your Medical Records Coders will have to look at both records as one and appropriately apply the correct diagnosis, procedure, and POA codes. Unrelated readmissions are coded separately with each record standing on its own.
  • Combine the two claims into one for related same-day readmissions by the Billing Department. If the claim for the first admission has already been submitted, it will need to be cancelled and a new or adjusted combined claim submitted. Remember that coding will need to be revised for combined claims before they are submitted. For unrelated same-day readmissions, the condition code B4 will need to be added to the second admission.

As you can see, this requires several different hospital departments working together to get this right - definitely a team effort!

The Compliance newsletter also addresses some issues related to outpatient laboratory services. Laboratory services may be denied upon review by a Comprehensive Error Rate Testing (CERT) contractor due to lack of orders and/or documentation to support medical necessity or due to services exceeding frequency limits.

The issue of the ordering physician’s signature on a laboratory requisition has been the topic of much discussion for several years. And the final CMS decision – a laboratory requisition does not have to be signed by the ordering physician - is a little misleading. Because even though the requisition does not have to be signed, somewhere there must be a valid signed physician’s order or signed documentation supporting the intent to order the laboratory tests. There also must be documentation supporting the medical necessity for the lab services - a diagnosis code or medical condition reason for which the test is being ordered. These requirements can be met by having a physician’s signature and a documented diagnosis on the laboratory requisition. If the lab requisition is not signed or does not contain a supporting diagnosis, a valid order and proof of medical necessity must be submitted to the reviewer. This could be a copy of the physician’s office notes or other types of physician documentation. CERT may send a request for documentation to the referring physician, but remember it is the responsibility of the billing provider to supply the requested documentation regardless of the place of service. This same concept applies to other types of outpatient services such as DMEPOS and ambulance services.

Laboratory services that exceed Medicare’s established frequency limits may also be denied by automated edits or when reviewed by the CERT contractor. There are a number of lab tests and other services that have frequency limits. The newsletter gives examples of a Hepatitis C Screening test exceeding one per lifetime and a screening pap smear exceeding the limit of one every two years. The lab test that MMP most commonly sees exceeding the frequency limit is HCPCS code G0103, Screening PSA which is covered once a year for asymptomatic men over 50.

You may notice that all of the services with frequency limits mentioned above are preventive or screening services. Medicare preventive services, both lab and non-lab services, generally have frequency limits and there are several resources that describe the coverage conditions for preventive services. One such resource is . Some non-screening laboratory tests also have frequency limits: for example, hemoglobin A1C is generally only covered once every three months, with some exceptions, and a lipid panel is necessary once a year for monitoring or following patients with hyperlipidemia. It is often difficult for the testing laboratory or hospital to know when a patient last had a preventive service or a certain lab test. If you are concerned about loss of revenue due to exceeding frequency limits, remember it is acceptable to give patients an Advanced Beneficiary Notice of Non-Coverage (ABN) for services with frequency limits. For more information about ABNs see .

Hopefully healthcare professionals working together as a team can take care of patients, appropriately document their services, follow the Medicare and other payers’ rules, and submit a clean claim to obtain payment for their services. Not an easy task so working as a team is a must.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.