Category Archives: Compliance & RACs

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Attention Physicians and Coders: CMS’ Advanced Analytics Paying Off – Big Time

My mother taught me that it’s impolite to say “I told you so.” My daughter tells me I’m bossy and health care compliance is pretty dry (she’s trying not to be impolite and say “boring”) but when millions of dollars are connected, it’s much more interesting and news worthy.

So, sorry Mom, but I told you so and I’ve been telling you since I began blogging. And yes, big brother and his whole family are watching. Continue reading

Supervision and Incident-to Guidelines

In past blogs, I’ve written about a variety of E&M services and how to code those visits. In case that seemed straightforward, many years ago mid-level providers were added into the mix. You will see these types of providers abbreviated as MLP (mid-level providers), NPP (Non-physician practitioners), NP (Nurse Practitioners), PA (Physician’s Assistants), and some others. For the purpose of this blog, I’ll use MLP. The introduction of these types of providers created a new education opportunity for all of us. CMS created “Incident-to” guidelines and published them in the Medicare Benefit Policy Manual (S60.1-S60.4). This means that an MLP can provide services to a patient and report those services under the physician’s name when those services are provided incident to an established plan of care for that patient. Continue reading

A Tale of Two Hospitals…Ethics in Reporting Quality Outcomes

Pardon the bad play on words, but “it was the best of hospitals, it was the worst of hospitals.” Within the past week I interacted with two healthcare organizations and had the chance to discuss not only how they report, but improve their quality outcomes. In order to protect both the guilty and the innocent, I will only state that both are large academic medical centers with similar services, physician leadership and quality organizational structures. In comparing the two organizations, the gargantuan differences in reporting frustrate me, and the ethics of the leaders involved in quality at one institution frankly disgust me. How can we accurately measure, and ultimately improve, quality outcomes if all are not “playing” honestly? And yes, I acknowledge that “gaming” in quality scores has been occurring for decades. But does that make it right?
Continue reading

Where Would We Be Without Clinical Coders?

I’m sitting on a plane today, traveling through the air as a result of some very bright people that enabled this mode of transportation. I’m doing so safely, thanks to strict airport security practices. Many years ago, when more stringent airport security screening was established, I would listen to fellow travelers complain about the invasion of privacy, the maybe not-so-random searches and the added expense tacked on to everything. And the lines in security, oh the lines! However, as a frequent traveler I’m forever thankful for the process we flyers have to go through to ensure the safest passage possible. Continue reading

Observation Services: Documenting Medical Necessity (Part Two)

In last week’s blog, I discussed observation services and private payer requirements. Now let’s take a look at CMS requirements which are a bit different. Observation is expected to be used when the physician presumes the patient will need less than 48 hours of care and the time in the hospital does not cross two midnights. Specifically, CMS says “The physician’s ‘expectation …should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.’” The CMS clinical and time expectations are similar to BCBS of NC. Continue reading

Data Value: Important Mammogram Coding Change

A policy and data specialist colleague of mine was working with the 2015 NCCI data and noted that CMS had, for the first time, added screening and diagnostic mammogram codes to the edit.

Specifically, CPT 77055 and 77056 and HCPCS G0204 and G0206 (diagnostic mammography) and CPT 77057 (screening mammography) and 77063 (screening digital breast tomosynthesis, bilateral) cannot be billed on the same claim on the same date of service (DOS). Continue reading

Compliance Confusion: Observation Coding

I wonder how many millions of dollars are lost due to coding errors that have nothing to do with ICD-10 but everything to do with complex and confusing requirements and new rules. I’ve said this before: I don’t believe folks make mistakes intentionally, especially when it impacts reimbursement, but I think there is a lot of coding compliance confusion. And, in my humble opinion, it’s not the coders “fault” when errors are encountered. Continue reading

Whodunnit? Let’s be honest!

At the start of the New Year, I can’t help but reflect on how much patient care has changed in my 25+ years. Many things that were common practice back then were either not necessary or even sometimes harmful. An example would be Foley catheter placements. Foleys for “everyone” whether they needed them or not!

However, the advent of superbugs with increasing antibiotic resistance has also meant an increase in catheter-related UTIs. Organizations became focused on prevention, using different catheter materials thought to prevent colonization, and by evaluating the need for insertion and/or continued placement. It certainly didn’t hurt that catheter-associated UTIs (CAUTIs) were determined to be hospital-acquired preventable conditions that CMS would not reimburse, and were also factored into quality outcomes metrics by quality assessment programs or organizations. Continue reading

Resolution 2015: Time to Audit

Like many, the end of the year is a time of reflection and planning for me. Where did I succeed in 2014 and where do I need to focus in 2015?

One of my plans for 2015 is cleaning the basement. I know, I hate doing it too – that’s why I had to make it a resolution – give it more emotional power.

My daughter graduated from college in 2006 and wanted to “leave some of my stuff here temporarily.” It’s now 2015 and that stuff is still in my basement. Does she need it? Likely not, since it hasn’t seen the light of day in nine years. But before it’s moved, we’re going to go through it and throw out what’s no longer needed. I’ve learned that it makes more sense both from a time and cost perspective, to clean up before a move than to pack, move, unpack and then throw out the same stuff. Continue reading

CMS is Serious about Overuse of Modifiers: More on 59

On September 10, 2014, OIG announced it settled with a physician group practice in Illinois for overuse of modifiers.  The practice exceeded the number of units allowed for certain services as regulated by CMS. According to the OIG, the physician practice used a code to bypass computer edits that otherwise would have rejected their claims. The group entered into a $590,763.45 settlement to resolve allegations of submitting false or fraudulent claims to Medicare. In addition, OIG contends the group upcoded services and submitted claims for high complexity tests when it performed less expensive, low or moderate complexity tests.

My take:

In September, I posted a blog regarding the modifications CMS plans to make to modifier 59 by creating four new, more specific modifiers that can be used to bypass an NCCI edit. CMS is requiring providers to be more specific with regard to what they believe a separate service really is. What is not new is that using the new modifiers will require documentation that adequately supports their use. A few thoughts on the new modifiers: Continue reading