Friday, December 6, 2013

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.
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.

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 medicationG8126: 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 reasonsG8128: 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 givenG8127: 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 & G8930are 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 [1040-8Por one G-code [G8931are 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 assessedG8932: Suicide risk assessed at the initial evaluation
Patient is not eligible for this measure because MDD is in remissionCPT II 3092F: Major depressive disorder, in remission
Suicide risk not assessed, reason not givenG8933: 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 requiredG8420: Calculated BMI within normal parameters and documented
BMI calculated above normal parameters, follow-up documentedG8417: Calculated BMI above normal parameters and a follow-up plan was documented
BMI calculated below normal parameters, follow-up documentedG8418: Calculated BMI below normal parameters and a follow-up plan was documented
BMI not calculated, patient not eligible/not appropriateG8422: Patient not eligible for BMI calculation
BMI calculated, patient not eligible/not appropriate for follow-up planG8938: BMI is calculated, but patient not eligible for follow-up plan
BMI not calculated, reason not givenG8421: BMI not calculated
BMI calculated outside normal parameters, follow-up plan not documented, reason not givenG8419: 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 documentedG8427: 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 eligibleG8430: Eligible professional attests the patient is not eligible for medication documentation
Current medications with name, dosage, frequency, route not documented, reason not givenG8428: 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, 96150Pain assessment documented as positiveG8730: 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 requiredG8731: Pain assessment documented as negative, no follow-up plan required
Patient not eligible for pain assessment for documented reasonsG8442: Documentation that patient is not eligible for a pain assessment
Pain assessment documented, follow-up plan not documented, patient not eligible/appropriateG8939: Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate
Pain assessment not documented, reason not givenG8732: No documentation of pain assessment, reason not given
Pain assessment documented as positive, follow-up plan not documented, reason not givenG8509: 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 documentedG8431: Positive screen for clinical depression with a documented follow-up plan
Negative screen for clinical depression documented, follow-up plan not requiredG8510: Negative screen for clinical depression, follow-up not required
Screening for clinical depression not documented, patient not eligible/appropriateG8433: Screening for clinical depression not documented, patient not eligible/appropriate
Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriateG8940: Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriate
Screening for clinical depression not documented, reason not givenG8432: 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 methodCPT II 3016F
Unhealthy alcohol use screening not performed, for medical reasons3016F 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 specified3016F 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 documentedG8733: 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 requiredG8734: Elder maltreatment screen documented as negative, no follow-up required
Elder maltreatment screen not documented, patient not eligibleG8535: No documentation of an elder maltreatment screen, patient not eligible
Elder maltreatment screen documented, patient not eligible for follow-upG8941: Elder Maltreatment Screen Documented, Patient not Eligible for Follow-Up
Elder maltreatment screen not documented, reason not givenG8536: No documentation of an elder maltreatment screen, reason not given
Elder maltreatment screen documented as positive, follow-up plan not documented, reason not givenG8735: 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 useCPT 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 tobaccoCPT II 1036F: Current tobacco non-user
Tobacco screening not performed for medical reasons4004F 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 specified4004F 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 dependenceCPT 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 specified4320F 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 depressionCPT II 1220F: Patient screened for depression
Patient not screened for depression for medical reasons1220F with 1P: Documentation of medical reason(s) for not screening for depression
Patient not screened for depression, reason not otherwise specified1220F 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 conditionG8959:Clinician treating MDD communicates to clinician treating comorbid condition
Clinician treating Major Depressive Disorder did not communicate to clinician treating comorbid condition, reason not givenG8960: Clinician treating MDD did not communicate to clinician treating comorbid condition, reason not given