Pediatric Coding Alert

CMS says that improper Medicaid claims skyrocketed last year—ensure that you aren’t one of the wrongdoers.

Because pediatricians don’t typically treat Medicare patients, chances are strong that you aren’t completely familiar with the government’s audit program. But if a new Medicaid E-Alert is any indication, your state Medicaid program could increase its focus on your practice to ensure that you aren’t paid improperly.

Background: In August, CMS issued its “Medicaid Improper Payments E-Alert,” which outlined the 9.8 percent improper payment rate that Medicaid calculated for 2015. Although an error rate below ten percent may not sound too severe, that number represents a startling $29.12 billion.

CMS is intent on ensuring that the number doesn’t rise further next year, so the agency put together a list of contributing factors that prompted the high improper payment rate, along with suggestions on how to fix such problems going forward.

We’ve read through this document and extracted the three issues most common to pediatric practices, along with solutions on how to ensure that your claims are paid accurately the first time.

Issue 1: Inappropriate or Insufficient Documentation.

Medicaid reviewers discovered issues with providers whose documentation did not meet the criteria to report the codes billed. “Medicaid takes the position that if the work is not properly documented, do not bill the services,” the E-Alert says.

Example: Suppose the pediatrician performs an E/M service for a child with ADHD and discovers that the patient’s family has a history of heart conditions. The pediatrician performs an electrocardiogram (ECG) to further assess the patient before treating him ADHD medication so he can be sure that the patient isn’t affected with the same heart condition as his family members, which would be a contraindication for the drugs.

However, the physician’s documentation simply says “ADD check.” Upon audit, the Medicaid insurer does not consider that sufficient medical necessity to pay for an ECG, so you must return the approximately $20 you received for billing 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report).

Tip: Always document every aspect of the patient’s care, risk factors, and concomitant issues, including their Past, Family, and Social History (PFSH), says Allison O’Neal of Traxel Pediatrics in New York, NY. “In a situation like this, it can not only support the E/M level you report, but also the ECG as well.”

Issue 2: Incorrect Coding and Medically Unlikely Edits

Although you may do your best to report the right codes, the fact is that many practices bill Medicaid with incorrect codes or else they unbundle services that should be billed with one global code—and CMS is urging state Medicaid agencies to launch audits to find the offenders.

“Some services are bundled for billing, like surgery and the follow-up care, and should be billed with one code,” the E-Alert says. “Audit to ensure such bundled services are not billed separately.”

Example: Your pediatrician performs a circumcision with a nerve block and reports both 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block) and 64450-59 (Injection, anesthetic agent; other peripheral nerve or branch; Distinct procedural service). Although the code descriptor for 54150 clearly states “with regional dorsal penile or ring block,” the state Medicaid payer does not have an edit in place barring the practice from reporting the codes together, and the claims system pays the claim thanks to the modifier 59 addition, allowing the practice to collect $150 for the circumcision and another $82 for the nerve block.

An audit would reveal the fact that the practice has been unbundling these services, and the practice would be bound to refund the charges for 64450 back to the insurer.

Tip: Consult payer guidelines, Correct Coding Initiative edits, and CPT^® rules to determine which services are allowed to be billed separately and which would constitute unbundling if you reported them on the same claim.

Issue 3: Services Covered by Another Payer

If a patient has insurance with Medicaid as well as with another insurer, the other insurer will always be considered the primary payer. “Medicaid is the payer of last resort,” the E-Alert says.

Example: A patient presents with both Tricare and Medicaid. Knowing that Tricare is always the secondary insurer, you bill Medicaid as the primary payer and then you submit any balance to Tricare.

Reality: This would be accurate if the patient had both private insurance and Tricare, but Medicaid always gets billed last, even if Tricare is the other payer.

Tip: Always verify coverage through the coordination of benefits program before a patient presents to your practice so you know exactly what types of coverage they have. If a patient has another insurer in addition to Medicaid, do not bill Medicaid until the other insurers have already processed the claims.

Resource: To read the complete E-Alert, visit https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/e-alerts-improper-payments.pdf.