Medicare claims JFK Medical Center overbilled

A federal audit of JFK Medical Center in Atlantis found that it overbilled Medicare by $4.4 million.

The 460-bed hospital, part of HCA (NYSE: HCA), had its 2009 and 2010 Medicare billings reviewed by the U.S. Department of Health and Human Services’ Office of Inspector General (OIG), which released the report Wednesday. It recommended that the government attempt to recoup the money. The hospital is contesting the findings.

The auditors selected a $25.2 million portion of potentially erroneous claims out of $208 million in Medicare claims filed by the hospital for those years. Of that, 200 claims for $1.32 million were closely examined as a random sample.

While the OIG stated that JFK met Medicare billing requirements for the majority of its claims, it did not comply for 70 inpatient claims, totaling $293,869, out of the sample group that was examined. The most common error was billing claims as inpatient when they should have been considered outpatient observation stays, which have a lower reimbursement rate. In some cases, the wrong diagnosis groups were assigned to the claims.

The OIG extrapolated those findings to the $1.32 million sample size – assuming the same ratio of claims were overbilled – and declared that the hospital owes $4.4 million.

“Overpayments occurred primarily because the hospital did not have adequate controls to prevent incorrect billings of Medicare claims within the selected risk areas that contained errors,” the OIG stated in its study.

RELATED CONTENT: UM hospital owes $3.7M in overbilled Medicare, feds say

In its response, JFK said the government should be barred from recovering the alleged overpayments from 2009 because they are more than three years old, which is the deadline for such action. It also contested that 39 of those 70 inpatient claims were overbilled. In many of these cases, the patients’ physicians ordered that they be admitted to the hospital, and JFK simply followed their instructions, the hospital stated.

In addition, JFK said it’s not fair to extrapolate the alleged errors found to the larger group of claims to inflate the overbilling findings.

“Such extrapolation is erroneous as a matter of law, statistical integrity and fundamental fairness,” JFK stated in its official response to the OIG.

JFK added that it would strengthen its Medicare billing compliance.

http://www.blogger.com/blogger.g?blogID=4916783830942487270#editor/src=header

Preparing for ICD-10, CMS goals for Small and Medium Sized Practices

This is a pretty good time to check and see if you’re on track for ICD-10 implementation. According to the Centers for Medicare and Medicaid Services (CMS), that means small- and medium-sized medical practices should have completed some goals.

Planning

These steps should be completed:

• Identify resources
• Create project team
• Assess effects
• Create project plan
• Secure budget

Communications

Practices also should have:

• Informed staff
• Contacted vendors
• Contacted payers

Medical practices need to stay in contact with their vendors and payers to track and monitor their ICD-10 progress. Hopefully contingency plans won't be needed.

Testing

Key personnel involved in ICD-10 testing should be trained. And CMS recommends testing the following elements for internal testing:

• Database architecture
• User interfaces
• Algorithms based on diagnosis or institutional procedure codes
• Code aggregation (grouping) models
• Key metrics related to diagnosis or institutional procedure codes
• All reporting logic based on diagnosis or institutional procedure codes

That should be completed so medical practices can begin external testing with healthcare payers, which should include:

• Determine if the payer has educational programs and collaboration efforts to support providers through the transition
• Use the high-dollar, high-volume, high-risk scenarios that your practice has created to produce test claims
• Work with payers to develop test scenarios to conduct end-to-end testing, specifically identifying payment results
• Communicate coding practices and scenarios to payers to build better relationships throughout the testing and transition process
• Identify communication processes to identify and correct issues early with payers
• Test information exchanges with hospitals to ensure appropriate handling.
• Test healthcare information exchanges for critical operations to meet interoperability standards.
• Test outsourced coding and billing operations with defined clinical scenarios to make sure these business operations continue as expected.

Local and national government entities may require reporting for a variety of purposes including:

• Public health reporting
• Quality and other metric reporting related to meaningful use
• Medicare and Medicaid reporting and data exchange
• Other mandated or contractually required exchange of information around services and patient conditions

The external testing should be going on through Oct. 1. Mostly because not all trading partners will be at the same level of preparedness.

Quick reference guide for PQRS measures, procedure codes and G-codes

Once an eligible patient and measure are identified, use this chart to select the appropriate procedure and G-code

By Government Relations staff

Formerly known as the Physician Quality Reporting Initiative (PQRI), the Physician Quality Reporting System is a voluntary reporting program that provides a financial incentive for certain health care professionals, including psychologists, who participate in Medicare to submit data on specified quality measures to the Centers for Medicare and Medicaid Services (CMS). In 2015, the reporting program will shift from an incentive program that offers bonuses for successful reporting to one in which penalties will be assessed for failure to participate.

Reporting in PQRS consists of selecting measures that match your Medicare population and identifying the types of services you provide to those patients. Medicare asks that you indicate whether or not the action described by the measures was taken through the use of a code (known as a “G” code) specific to each measure.

This chart provides a quick summary of Physician Quality Reporting System (PQRS) measures (in orange) and the procedure codes and G-codes available for each measure, based upon action taken. Prior to using this chart, providers will need to determine which measure is applicable by examining their Medicare patient population and identifying those who have a diagnosis covered by an eligible measure.

For more information on identifying eligible patients and measures, view the video on How to Report in the Physician Quality Reporting System. For additional materials and resources related to PQRS, visit the Quality Improvement Programs section at the APA Practice Organization’s Practice Central website.

Applicable procedure codes	Action taken	G-code (or F-code where applicable)
Measure #9: Major depressive disorder: antidepressant medication during acute phase for patients with MDD
90791, 90832, 90834, 90837,  90845, 90849, 90853	Acute treatment with antidepressant medication	G8126: Patient with new episode of MDD documented as being treated with antidepressant medication during the entire 12 week acute treatment phase
	Acute treatment with antidepressant medication not completed for documented reasons	G8128: Clinician documented that patient with a new episode of MDD was not an eligible candidate for antidepressant medication treatment or patient did not have a new episode of MDD
	Acute treatment with antidepressant medication not completed, reason not given	G8127: Patient with new episode of MDD not documented as being treated with antidepressant medication during the entire 12 week acute treatment phase
#106: Major depressive disorder: diagnostic evaluation
90791, 90832, 90834, 90837,  90845	DSM-IV-TR criteria for Major Depressive Disorder documented (One CPT II code & one G-code [1040F & G8930] are required on the claim form to submit this numerator option)	CPT II 1040F: DSM-IV-TR criteria for major depressive disorder documented at the initial evaluation  and G8930: Assessment of depression severity at the initial evaluation
	DSM-IV-TR criteria for Major Depressive Disorder not documented, reason not otherwise specified (One CPT II code [1040-8P] or one G-code [G8931] are required on the claim form to submit this numerator option)	1040F with 8P: DSM-IV-TR criteria for major depressive disorder not documented at the initial evaluation, reason not otherwise specified or  G8931: Assessment of depression severity not documented, reason not given
#107: Major depressive disorder: suicide risk assessment
90791, 90832, 90834, 90837,  90845	Suicide risk assessed	G8932: Suicide risk assessed at the initial evaluation
	Patient is not eligible for this measure because MDD is in remission	CPT II 3092F: Major depressive disorder, in remission
	Suicide risk not assessed, reason not given	G8933: Suicide risk not assessed at the initial evaluation, reason not given
#128: Preventive care and screening: Body mass index screening and follow-up
90791, 90832, 90834, 90837	BMI calculated as normal, no follow-up plan required	G8420: Calculated BMI within normal parameters and documented
	BMI calculated above normal parameters, follow-up documented	G8417: Calculated BMI above normal parameters and a follow-up plan was documented
	BMI calculated below normal parameters, follow-up documented	G8418: Calculated BMI below normal parameters and a follow-up plan was documented
	BMI not calculated, patient not eligible/not appropriate	G8422: Patient not eligible for BMI calculation
	BMI calculated, patient not eligible/not appropriate for follow-up plan	G8938: BMI is calculated, but patient not eligible for follow-up plan
	BMI not calculated, reason not given	G8421: BMI not calculated
	BMI calculated outside normal parameters, follow-up plan not documented, reason not given	G8419: Calculated BMI outside normal parameters, no follow-up plan documented
#130: Documentation and verification of current medications in the medical record
90791, 90832, 90834, 90837, 90839, 96116, 96150, 96152	Current medications documented	G8427: Eligible professional attests to documenting the patient’s current medications to the best of his/her knowledge and ability
	Current medications not documented, patient not eligible	G8430: Eligible professional attests the patient is not eligible for medication documentation
	Current medications with name, dosage, frequency, route not documented, reason not given	G8428: Current medications not documented by the eligible professional, reason not given
#131: Pain assessment prior to initiation of patient therapy and follow-up
90791, 96116, 96150	Pain assessment documented as positive	G8730: Pain assessment documented as positive utilizing a standardized tool and a follow-up plan is documented
	Pain assessment documented as negative, no follow-up plan required	G8731: Pain assessment documented as negative, no follow-up plan required
	Patient not eligible for pain assessment for documented reasons	G8442: Documentation that patient is not eligible for a pain assessment
	Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate	G8939: Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate
	Pain assessment not documented, reason not given	G8732: No documentation of pain assessment, reason not given
	Pain assessment documented as positive, follow-up plan not documented, reason not given	G8509: Documentation of positive pain assessment; no documentation of a follow-up plan, reason not given
#134: Screening for clinical depression and follow-up plan
90791, 90832, 90834, 90837, 96150, 96151	Positive screen for clinical depression documented, follow-up plan documented	G8431: Positive screen for clinical depression with a documented follow-up plan
	Negative screen for clinical depression documented, follow-up plan not required	G8510: Negative screen for clinical depression, follow-up not required
	Screening for clinical depression not documented, patient not eligible/appropriate	G8433: Screening for clinical depression not documented, patient not eligible/appropriate
	Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriate	G8940: Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriate
	Screening for clinical depression not documented, reason not given	G8432: Clinical depression screening notdocumented, reason not given
#173: Preventive care and screening: Unhealthy alcohol use—screening
90791, 90832, 90834, 90837,  90845, 96150, 96152	Patient screened for unhealthy alcohol use using a systematic screening method	CPT II 3016F
	Unhealthy alcohol use screening not performed, for medical reasons	3016F with 1P: Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectancy, other medical reasons)
	Unhealthy alcohol use screening not performed, reason not otherwise specified	3016F with 8P: Unhealthy alcohol use screening not performed, reason not otherwise specified
#181: Elder maltreatment screen and follow-up plan
90791, 96116, 96150	Elder maltreatment screen documented as positive and follow-up plan documented	G8733: Documentation of a positive elder maltreatment screen and documented follow-up plan at the time of the positive screen
	Elder maltreatment screen documented as negative, follow-up plan not required	G8734: Elder maltreatment screen documented as negative, no follow-up required
	Elder maltreatment screen not documented, patient not eligible	G8535: No documentation of an elder maltreatment screen, patient not eligible
	Elder maltreatment screen documented, patient not eligible for follow-up	G8941: Elder Maltreatment Screen Documented, Patient not Eligible for Follow-Up
	Elder maltreatment screen not documented, reason not given	G8536: No documentation of an elder maltreatment screen, reason not given
	Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given	G8735: No documentation of an elder maltreatment screen, patient not eligible
#226: Preventive care and screening: Tobacco use assessment and tobacco cessation intervention
90791, 90832, 90834, 90837,  90845, 96150, 96151, 96152	Patient screened for tobacco use	CPT II 4004F: Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user
	Patient screened for tobacco use and identified as a non-user of tobacco	CPT II 1036F: Current tobacco non-user
	Tobacco screening not performed for medical reasons	4004F with 1P: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)
	Tobacco screening or tobacco cessation intervention not performed reason not otherwise specified	4004F with 8P: Tobacco screening or tobacco cessation intervention not performed, reasonnot otherwise specified
#247: Substance use disorders – counseling
90791, 90832, 90834, 90837,  90845, 96150, 96152	Patient counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence	CPT II 4320F: Patient counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence
	Patient not counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence, reason not otherwise specified	4320F with 8P: Patient was not counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence, reason not otherwise specified
#248: Substance use disorders Screening for depression
90791, 90832, 90834, 90837,  90845, 96150, 96152	Patient screened for depression	CPT II 1220F: Patient screened for depression
	Patient not screened for depression for medical reasons	1220F with 1P: Documentation of medical reason(s) for not screening for depression
	Patient not screened for depression, reason not otherwise specified	1220F with 8P: Patient was not screened for depression, reason not otherwise specified
#325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions – Note: Registry Reporting Only
90791, 90832, 90834, 90837,  90845	Clinician treating Major Depressive Disorder communicates to clinician treating comorbid condition	G8959:Clinician treating MDD communicates to clinician treating comorbid condition
	Clinician treating Major Depressive Disorder did not communicate to clinician treating comorbid condition, reason not given	G8960: Clinician treating MDD did not communicate to clinician treating comorbid condition, reason not given

http://www.apapracticecentral.org/update/2013/02-14/procedure-codes.aspx