Medicare has found that approximately 85% of improper payments relating to the billing of implantable automatic defibrillators were due to insufficient documentation.
This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers to avoid common billing errors and other erroneous activities when dealing with the Medicare Program.
The figure was determined through a Comprehensive Error Rate Testing (CERT) program's special study of Healthcare Common Procedure Coding System (HCPCS) code 33249 (Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber).
The Centers for Medicare & Medicaid Services (CMS) calculates the Medicare Fee-for-Service (FFS) improper payment rate through the CERT program. Each year, CERT evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.
Implantable automatic defibrillators are electronic devices designed to detect and treat life-threatening rapid heart rates. The device consists of a pulse generator and electrodes for sensing and defibrillating, and they are commonly referred to as Automatic Implantable Cardioverter Defibrillators (AICDs).
Insufficient Documentation and Medical Necessity Errors
Insufficient documentation means that required information is missing from the medical records or is inadequate to support payment. The CERT study found that approximately 85 percent of the improper payments were due to insufficient documentation, and this included lack of:
In the CERT study, medical necessity errors caused approximately 12 percent of the improper payments. A medical necessity error occurs when the CERT reviewer receives adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary, based upon Medicare coverage policies.
1. For all AICDs, the beneficiary must not have irreversible brain damage from preexisting cerebral disease; also
2. For primary prevention of sudden cardiac death, criteria include that the beneficiary must not have:
Examples of Improper Payments for AICDs
Example 1: Improper Payments due to Insufficient Documentation for AICDs
A physician billed for insertion of an AICD using HCPCS 33249 and modifier Q0 (Investigational clinical service provided in a clinical research study).
Review of the documentation found that the following was missing:
1. Clinical documentation supporting a previous Myocardial Infarction (MI) (documented and defined according to the consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction);
2. Clinical documentation supporting the defibrillator implantation for primary prevention is enrolled in either:
The CERT reviewer also received a device implant report for the correct date of service showing implantation of two leads, removal of a previous pacemaker, and threshold testing of the device with induced ventricular fibrillation and shock. The physician signed the report and authenticated the electrophysiology report. Additional information was requested and several unauthenticated clinical records were received that supported the beneficiary's history of heart disease.
However, the beneficiary's condition did not meet the criteria for Medicare coverage of an AICD. Although AICDs that are not covered based on Medicare coverage criteria are covered under Category B IDE trials and the CMS routine clinical trials policy, there was no documentation of enrollment in a clinical trial in this case.
There was no support for the use of the Q0 modifier in the documentation received, so this claim was scored as an insufficient documentation error and the Medicare Administrative Contractor (MAC) recouped the payment from the provider.
Example 2: Improper Payments due to Insufficient Documentation for AICDs
A physician billed for HCPCS 33249 at time of initial AICD implantation. The submitted documentation showed that the 73 year-old beneficiary had a past medical history of pulmonary hypertension, severe left ventricular dysfunction, non-ischemic dilated cardiomyopathy, dyslipidemia, and congestive heart failure (New York Heart Association Class III). The patient's symptoms included shortness of breath, fatigue, intermittent swelling in his feet, and he was unable to sleep lying flat. He was on maximal medical therapy that included Beta blockers, Angiotensin-Converting Enzyme (ACE) inhibitors, and diuretics. His cardiac catheterization showed an ejection fraction of 30 percent.
An operative report showed that he had an AICD implanted; however, the date on the report did not match the billed date of service. Medicare payment rules do not allow reviewers to accept documents with dates that are significantly different from the billed date of service.
This claim was scored as an insufficient documentation error , and the MAC recouped the payment from the provider.
Example 3: Improper Payments due to Medical Necessity Errors for AICDs
A cardiac surgeon billed for HCPCS 33249. He/she submitted medical records showing that the beneficiary had dilated ischemic cardiomyopathy with paroxysmal atrial fibrillation and that he had a Coronary Artery Bypass Graft (CABG) procedure 16 days prior to the AICD implantation.
There was no documentation of a prior MI or of an investigational research study. Documentation included an unsigned post-operative history and physical examination note. The CERT reviewer requested additional documentation to support this claim and received a copy of the previously unsigned post-operative history and physical examination note to which a signature had been added without a signature date.
Note: Providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead should make use of the signature authentication process.
The related NCD requires that the beneficiary must not have had a CABG within 3 months prior to the AICD implantation.
The submitted documentation did not support the NCD requirements for reasonable and necessary services. This claim was scored as a medical necessity error and the MAC recouped the payment from the provider.
Amendments, Corrections and Delayed Entries in Medical Documentation
Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service.
A provider may discover that certain entries related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service. When making review determinations, the Medicare review contractors consider all submitted entries that comply with the widely accepted Recordkeeping Principles described in the "Medicare Program Integrity Manual," (Section 18.104.22.168 (Amendments, Corrections and Delayed Entries in Medical Documentation), Section B (Recordkeeping Principles); see the Resources section below). MACs, CERT, Recovery Auditors, and Zone Program Integrity Contractors (ZPICs) DO NOT consider any entries that do not comply with the principles listed in Section B, even if such exclusion would lead to a claim denial. For example, Medicare review contractors exclude from consideration undated or unsigned entries handwritten in the margin of a document.
Cardiology billing is complex, requiring a high level of experience and knowledge for appropriate coding and general medical billing procedures. Billing specifics such as checking medical necessity verification and component coding require ever increasing levels of billing expertise and efficiency.
PGM has over thirty years of experience in cardiologist billing. Contact PGM to learn how we can manage all aspects of your practice's billing to help ensure you receive proper reimbursement for services provided.
After months of debate, the health care reform bill finally passed and has been signed into law by President Obama. It is legislation that is slated to cover millions of Americans who don't have health insurance and drive down insurance costs that have been on the rise since the start of the millennium.
The reform bill has two phases. First, here are some things that Americans saw change change in the first 6 months the bill was in effect:
Other concerns of the new health care reform bill:Many people are also concerned about longer waits to visit their doctor with this new increased, centralized government health insurance bill, such as what happened in Massachusetts. This will very likely not be the case because in Massachusetts, they made all their changes at once and it wasn't feasible to overload the pre-existing system with those changes. The new national bill phases in these changes over time so that the system can adapt.
Wait times are also expected to go down at emergency rooms at hospitals, where wait times have been steadily increasing over the last decade. Patients who are covered under the new bill who were not before are expected to go to a primary care physician instead of directly to the emergency room for one-time treatments.
Also built into the bill is millions of dollars for community health centers that are expected to be able to take on tens of millions of patients so that your primary care physician isn't held up by the increase in patients covered.
A not-so-well-known part of the bill:Sweeping changes in the student loan program, an administration priority that has been stalled in the Senate for months, will now be in effect. They will have the government originate all student loans, denying banks and other private lenders of a lucrative business they have long had through government paid fees. Much of the savings would go into increased Pell Grants for needy college students, but black and Hispanic colleges would also benefit.
Of course this is only the beginning of the reform as many of the provisions set for 2014 could be changed by amendments and other legislation before then, but when they do, we'll be on your side with what those changes mean.
Do you think this is a good bill for America? For you? For your neighbors? Let us know in the comments section below and vote in our poll.
In a new "CPT for ENT" article, the American Academy of Otolaryngology — Head and Neck Surgery (AAO-HNS) addresses a question on coding for implantation of a hypoglossal nerve stimulator.
CPT for ENT articles are a collaborative effort between AAO-HNS's team of CPT advisors, members of the Physician Payment Policy workgroup and health policy staff.
The question tackled in this latest CPT for ENT article is as follows:
Q: How do I code for implantation of a hypoglossal nerve stimulation system that includes placement of a chest wall sensor(s)?
To view the answer on the AAO-HNS website, click here.
The American Chiropractic Association provides a free, valuable coding and billing resource you can access regardless of whether you are a member of ACA.
"ICD-10 Implementation for the Chiropractic Clinic" is a previously recorded webinar presented on behalf of ACA by Nicholas Payne, DC, an ACA insurance liaison from Kentucky.
The webinar's objectives are identified as follows:
Note: Oct. 1, 2015, was recently confirmed as the new compliance date for healthcare providers to make the transition to ICD-10.
Laboratory billing is under great scrutiny by federal regulators as indicated by a series of developments this year.
OIG Special Fraud Alert
In June, the Department of Health and Human Services Office of Inspector General (OIG) issued a Special Fraud Alert regarding laboratory payments to referring physicians (pdf). According to OIG, this Special Fraud Alert addresses compensation paid by laboratories to referring physicians and physician group practices for blood specimen collection, processing and packaging, and for submitting patient data to a registry or database.
The Alert describes two specific trends OIG has identified involving transfers of value from laboratories to physicians that we believe present a substantial risk of fraud and abuse under the anti-kickback statute.
The first involves blood specimen collection, processing and packaging arrangements under which clinical laboratories are providing remuneration to physicians to collect, process and package patients’ specimens. While Medicare allows the person who collects a specimen to bill Medicare for a nominal specimen collection fee in certain circumstances, there are a number of arrangements that may be problematic. According to OIG, these include when:
The second OIG trend concerns registry payments. OIG indicated it had become aware of arrangements under which clinical laboratories are establishing, coordinating or maintaining databases, either directly or through an agent, purportedly to collect data on the demographics, presentation, diagnosis, treatment, outcomes or other attributes of patients who have undergone, or who may undergo, certain tests performed by the offering laboratories.
While registry arrangements may take various forms, OIG notes they typically involve payments from laboratories to physicians for certain specified duties, such as submitting patient data to be incorporated into the registry, answering patient questions about the registry and reviewing registry reports. Registry arrangements may induce physicians to order medically unnecessary or duplicative tests, including duplicative tests performed for the purpose of obtaining comparative data, and to order those tests from laboratories that offer registry arrangements in lieu of other, potentially clinically superior, laboratories.
OIG notes that whether any particular registry arrangement violates the anti-kickback statute depends on the intent of the parties to the arrangement. Payments from a laboratory to a physician to compensate the physician for services related to data collection and reporting may be reasonable in certain limited circumstances. However, the anti-kickback statute prohibits the knowing and willful payment of such compensation if even one purpose of the payments is to induce or reward referrals of federal healthcare program business.
Some possible arrangements identified by OIG that may be evidence of unlawful purposes include the following:
Study: Questionable Billing for Medicare Part B Clinical Laboratory Services
In early July, OIG issued its study, "Questionable Billing for Medicare Part B Clinical Laboratory Services (pdf)" (which was later corrected and reissued in mid-August) The objective was to identify questionable billing for Part B clinical laboratory (lab) services in 2010.
The study analyzed Part B claims for lab services with dates of service in 2010. When labs submit claims for each lab service provided for Medicare beneficiaries, each claim contains information about the lab provider, the ordering physician, the beneficiary and the lab service. Researchers developed 13 measures to describe labs' billing patterns and identify labs with questionable billing patterns. They then calculated and analyzed the distribution of the measures for each lab, and then calculated a statistical threshold for the 13 measures and determined whether a lab's billing was unusually high for each measure. Additionally, they calculated the total number of claims and total allowed amount associated with certain measures of questionable billing.
Researchers found that in 2010, more than 1,000 labs exceeded the thresholds (i.e., had unusually high billing) for five or more measures of questionable billing for Medicare lab services. For example, a lab might have an unusually high percentage of claims with ineligible and/or invalid ordering-physician numbers, or an unusually high allowed amount per ordering physician. Some labs that exceeded the thresholds for fewer than five measures also exhibited billing that may warrant further review. Medicare allowed $1.5 billion across all labs for claims associated with questionable billing.
The OIG notes that while there may be some labs that have legitimate reasons for exceeding certain thresholds, collectively, these findings call for stronger oversight of labs and identification of specific issues with Medicare payments for lab services that need to be addressed to more effectively safeguard Medicare.
OIG recommended that CMS:
CMS concurred with all recommendations.
Laboratories Under Investigation
In September, it became apparent that the feds were serious about cracking down on illegal payments by labs to physicians.
As the Wall Street Journal reports, Virginia's Health Diagnostic Laboratory is being investigated by the Justice Department for its payments of blood-sample fees to doctors. The company's CEO has resigned amid the investigation.
The Pittsburgh Post-Gazette reports Universal Oral Laboratories of Pennsylvania is also subject of a federal investigation, with prosecutors alleging that the lab's owner built the business by giving kickbacks to doctors for sending patients' saliva samples for prescription drug adherence testing.
Boston Heart Diagnostics Corp. in Boston is another lab under investigation, according to a Boston Globe report. Federal investigators are examining whether diagnostic firms, including Boston Heart, has improperly paid doctors who send them patients' blood specimens to test their risk for cardiovascular disease.
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For more than 30 years, PGM Billing, a leading physician billing company, has worked with reference and clinical labs. PGM has developed one of the most effective lab billing, coding and financial management services on the market. To learn about what PGM and its team of expert lab billers and coders can do for you, contact us today.
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