Medicare Compliance & Reimbursement

Example: The anesthesiologist begins administering continuous anesthesia for a surgery at 11 p.m. on Sept. 30, 2013, and completes the administration at 2 a.m. on Oct. 1, 2013. Should the physicians involved report ICD-9 codes, since the date of service began before the ICD-10 implementation dates? You can't report both ICD-9 and ICD-10 codes on the same claim, CMS has said -- those claims will be returned to providers unpaid and marked as "unprocessable."

Solution: CMS answers this question with new Transmittal 950, released on Aug. 19, which breaks down how each facility should report claims that span the ICD-10 implementation date. Following you'll find some examples of how various providers will report these claims:

Inpatient hospitals: Use the "through" date -- If the hospital's discharge and/or through date occurs on or after Oct. 1, 2013, then the whole claim will be billed with ICD-10 codes.

Part B hospital services, outpatient hospitals, outpatient therapy, hospices, renal disease providers, and outpatient home health: You'll split the claim, so all ICD-9 codes remain on one claim and all ICD-10 codes remain on the other claim.

Anesthesia: Use ICD-9 codes and list Sept. 30, 2013 as both the "from" and "through" dates.

To read Transmittal 950, which includes the full list of potential provider types, visit www.cms.gov/transmittals/downloads/R950OTN.pdf.

If you've ever wondered about the logic behind Medicare's overpayment recovery system, CMS finally spells it out clearly in a new brochure entitled The Medicare Overpayment Collection Process.

Essentially, if your MAC finds that it overpaid you by $10.00 or more, it will initiate the overpayment recovery process, which begins with a demand letter requesting payment. If you don't respond within 30 calendar days after that letter's date, the MAC may send a second letter.

If the MAC doesn't receive full payment within 40 calendar days of the first demand letter, it will recoup your overpayment from future claims that you submit. In cases where you don't pay back the overpayment and the MAC does not recoup it, the contractor can send an Intent to Refer letter indicating that it can refer the overpayment to the Department of Treasury for collection.

You are eligible to rebut or appeal the demand letters, or set up a repayment plan if necessary. For details on this process, visit www.cms.gov/MLNProducts/downloads/OverpaymentBrochure508-09.pdf.

Submit your usual CMS enrollment changes in a timely manner, or you'll be sorry. That's the word from CMS, which is taking aim at practices that are using the revalidation process as an excuse to drag their heels about updating routine information.

"The Medicare provider enrollment revalidation effort does not change other aspects of the enrollment process," CMS says in an e-mail message to providers. "Providers should continue to submit routine changes -- address updates, reassignments, additions to practices, changes in authorized officials, information updates, etc. -- as they always have."

Even if you receive a revalidation request, you need to submit your changes separately from your revalidation information, CMS stresses.

A Florida physician is the latest practitioner to plead guilty as part of the government's smackdown on fraudulent Medicare billing.

As part of a $25 million fraud scheme allegedly perpetrated by ABC Home Health and Florida Home Health Care Providers Inc. in Miami, physician Jose Nunez pled guilty last week to prescribing medically unnecessary services, including home health and therapy, care plans and medical certifications, from January 2006 until March 2009, in exchange for kickbacks and bribes.

"Nunez admitted that he knew co-conspirators at ABC and Florida Home Health operated the agencies in order to bill the Medicare program for expensive physical therapy and home health care services that were medically unnecessary and/or were never provided," the Department of Justice says in a release.

Nunez allegedly falsified patient records with nonexistent symptoms to make the patients appear homebound and in need of insulin injections, says the release from the DOJ, FBI and the OIG. Nunez is scheduled for sentencing Dec. 5. The investigation was part of the HEAT program's Medicare Strike Force operation.