Look to MLN Newsletter for Top Billing Errors

The Centers for Medicare & Medicaid Services (CMS) has posted on its website the MLN Quarterly Provider Compliance Newsletter for April. The top billing errors for this month, detected by Comprehensive Error Rate Testing (CERT) and recovery auditors, all pertain to inpatient hospitals.

Three-day Rule

At the top of the list is a CERT finding for noncompliance of the three-day rule. It is inappropriate to admit a patient just to fulfill the three-day requirement and qualify that patient for a skilled nursing facility (SNF) stay, CMS says. To qualify for SNF services, a Medicare beneficiary must have been an inpatient of a hospital for a “medically-necessary” stay of at least three consecutive days. The day of admission, but not the day of discharge, is counted as an inpatient stay.

Certified Inpatient Coder CIC

Inpatient Hospital Consults

Another CERT finding has to do with inappropriate billing of the three evaluation and management (E/M) codes (99221-99223) now used in place of the former inpatient hospital consultation codes. When counseling and/or coordination of care dominates more than 50 percent of the unit/floor time spent caring for the beneficiary, time is the key or controlling factor in selecting the level of service.

“In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported,” CMS says in the newsletter.

The duration of counseling or coordination of care provided face-to-face or on the floor may be estimated. That estimate, along with the total duration of the visit, must be recorded in the medical record.

Recovery Audit Findings

Also in the April newsletter are five recovery audit findings for improper billing among inpatient hospitals. They are:

  • Cholecystectomy – Incorrect Secondary Diagnosis: Documentation must support all diagnoses.
  • Kidney and Urinary Tract Disorders – Incorrect Principal Diagnosis: Documentation must support all diagnoses.
  • Transient Ischemic Attack – Services Rendered in a Medically Unnecessary Setting: Requirements for inpatient status must be met.
  • Craniotomy and Endovascular Intracranial Procedures: Documentation must support all diagnoses. In this case, lack of documentation resulted in the removal of a diagnosis code that, in turn, changed the Medicare Severity Diagnosis-related Group (MS-DRG) assignment, resulting in an underpayment.
  • Small and Large Bowel Procedures: Documentation must support all diagnoses.
  • Spinal Fusion: Improper sequencing of diagnoses.

Read the April newsletter for complete details of these findings and more billing guidance that will help your providers stay in compliance.


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