Part B Insider (Multispecialty) Coding Alert
It's Good To Be Unusual -- But Not In Your Billing Practices
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Abnormal patterns trigger scrutiny by OIG, other watchdogs
Providers placing fistulas for dialysis will now have more opportunities to conduct that procedure, thanks to an initiative launched by Centers for Medicare & Medicaid Services April 14.
The owner of Baton Rouge, LA clinic Caldwell Medical Services faces a financial crisis after being charged with submitting 1,363 fraudulent claims over a one-year period that led to $598,240 in unallowable reimbursement from Medicare.
If your claim submissions stick out from those of your peers, make sure you have documentation to back up your services. Otherwise, you could end up on the fast track to an audit by the HHS Office of the Inspector General.
Unusual billing patterns recently sparked scrutiny of New York-based Nassau County Medical Center's psychiatry and psychology departments. According to U.S. Attorney Roslynn Mauskopf, from 1995 to 1999 attending physicians at NCMC made medically unnecessary rounds on weekends and holidays, and also allegedly billed Medicare for the medication management of psychiatric inpatients that was either not monitored as claimed or not prescribed at all.
A civil complaint filed by the government culminated in an April 15 settlement with Nassau County for $385,000 -- double the damages suffered by Medicare.
Through a contract with the Institute for Healthcare Improvement, CMS hopes that "Fistula First" will significantly increase the use of fistulas in hemodialysis for Medicare beneficiaries with end stage renal disease, and take a bite out of the burgeoning costs and health risks associated with more commonly used grafts and catheters.
And with 270,000 beneficiaries currently on dialysis, and twice that number expected by 2010, "Fistula First" could avert a healthcare crisis. The National Kidney Foundation's Dialysis Outcomes Quality Initiative recommends placement of fistulas in 50 percent of new dialysis patients with a long-range usage goal of 40 percent overall. CMS estimates the number of current beneficiaries with fistulas at only 30 percent.
Under CMS supervision and funding, the "Fistula First" project team will be working with dialysis providers, physicians, professional societies and patient advocacy groups to press for an overhaul of dialysis protocols.
To make sure you stay out of the red -- and off the government's watch list -- avoid similar billing mistakes: Hiring others to act on your behalf with Medicare while omitting or concealing your management role; calculating claims based on the number of body parts treated when reimbursement is based on the amount of time spent with patients; and misrepresenting the amount of co-pays received from beneficiaries.
Part B Insider (Multispecialty) Coding Alert
- Reimbursement:
Don't NOC It Until You Try
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Doctors [...] - Modifiers:
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Document that the physician discussed risks the first time
When you're providing global fracture care, the [...] - Use -76, -77 Modifiers for Repeat Closed Reductions
If the same physician has to go back and perform a closed reduction a second [...] - Unlisted Procedures:
NOC Versus -22 Modifier: Controversy And Judgment Calls
We'll show you the "most correct" code for every situation
If you're [...] - NOC Or -22:
Send Letter, Documentation
When you're billing with the -22 modifier or a Not Otherwise Classified (NOC) code, you [...] - Anatomy :
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Scan operative report for clues to bovine arch
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In Transmittal 147, issued April [...] - Add-On Codes:
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Don't accept payment reductions, or you could lose up to 50% on every claim
[...] - Part B Coding Coach:
4 Tips Improve Your 51701
Combat E/M and catheterization denials with documentation, diagnoses and modifier
When billing for office visits that [...] - Physician Notes:
It's Good To Be Unusual -- But Not In Your Billing Practices
Abnormal patterns trigger scrutiny by OIG, other watchdogs
If your claim submissions [...]