DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors

Updated Provider Index Now Available! See the Introduction section for more details Volume 4, Issue 3 - April 2014

ICN 909006/ April 2014 Table of Contents

Comprehensive Error Rate Testing (CERT): Psychiatry and Psychotherapy Services...... 1

Comprehensive Error Rate Testing (CERT): Computed Tomography (CT) Scans...... 4

Comprehensive Error Rate Testing (CERT): Preventive Services.....6

Recovery Auditor Finding: Durable Medical Equipment (DME) Group 2 – Pressure Reducing Support Surfaces...... 8

Recovery Auditor Finding: Group 2 Power Wheel Chairs...... 10

Recovery Auditor Finding: Multiple Surgery Reduction Errors: Single Line Modifier 51 Underpayments...... 14

Recovery Auditor Finding: CT Scans, Trunk and Extremities, Incorrect Billing...... 15

Recovery Auditor Finding: Office Visits Billed for Hospital Inpatients...... 17

Archive of Previously-Issued Newsletters

This educational tool was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This educational tool was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational tool may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network® (MLN), a registered trademark of CMS, is the brand name for official CMS educational products and information for Medicare Fee-For- Service Providers. For additional information, visit the MLN’s web page at http://go.cms.gov/MLNGenInfo on the CMS website. Your feedback is important to us and we use your suggestions to help us improve our educational products, services and activities and to develop products, services and activities that better meet your educational needs. To evaluate Medicare Learning Network® (MLN) products, services and activities you have participated in, received, or downloaded, please go to http://go.cms.gov/MLNProducts and click on the link called ‘MLN Opinion Page’ in the left-hand menu and follow the instructions. Please send your suggestions related to MLN product topics or formats to [email protected]. CPT only copyright 2013 American Medical Association. All rights reserved. ICD-9-CM Notice: The International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability and Accountability Act standard. Introduction

The Medicare Fee-For-Service (FFS) program contains a number of payment systems, with a network of contractors that processes more than one billion claims each year, submitted by more than one million providers, including hospitals, physicians, Skilled Nursing Facilities (SNFs), clinical laboratories, ambulance companies, and suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). These contractors are called Medicare Administrative Contractors (MACs) and they process claims, make payments to health care professionals in accordance with Medicare regulations, and educate providers on how to submit accurately coded claims that meet Medicare guidelines. Despite actions to prevent improper payments, such as pre-payment system edits and limited medical record reviews by the claims processing contractors, it is impossible to prevent all improper payments due to the large volume of claims. The Centers for Medicare & Medicaid Services (CMS) issues the “Medicare Quarterly Provider Compliance Newsletter,” a Medicare Learning Network® (MLN) educational product, to help providers understand the major findings identified by MACs, Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as the Office of Inspector General. This is the third issue in the fourth year of the newsletter. This issue includes five findings identified by Recovery Auditors and three items related to CERT findings. This educational tool is designed to help FFS providers, suppliers, and their billing staffs understand their claims submission problems and how to avoid certain billing errors and other improper activities when dealing with the Medicare FFS program. An archive of previously-issued newsletters is available at http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/downloads//MedQtrlyCompNL_ Archive.pdf on the CMS website. This newsletter describes the problems, the issues that may occur as a result, the steps CMS has taken to make providers aware of the problems, and guidance on what providers need to do to avoid the issues. In addition, the newsletter refers providers to other documents for more detailed information wherever that may exist. The findings addressed in this newsletter are listed in the Table of Contents and can be navigated to directly by “left-clicking” on the particular issue in the Table of Contents. A searchable index of keywords and phrases contained in both current and previous newsletters is available at http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNProducts/downloads// MedQtrlyCompNL_Index.pdf on the CMS website. In addition, a newly-enhanced index is now available that provides a listing of all Recovery Auditor and CERT Review Contractor findings from previous newsletters. The index is customized by specific provider types to help providers quickly find and learn about common billing and claim review issues that impact them directly. For more information, visit the newsletter archive at http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_ Archive.pdf on the CMS website.

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 III Comprehensive Error Rate Testing (CERT): Psychiatry and Psychotherapy Services

Provider Types Affected: Providers billing for psychiatric and psychotherapy services.

Background: The CERT program’s describes a service performed performed with an E&M service reviews of claims for Part B with another primary service. (list separately in addition to the Psychiatry and Psychotherapy • An add-on code is eligible for code for primary procedure). Services have identified many payment only if reported with Psychotherapy services improper payments. Effective an appropriate primary service provided without an E&M January 1, 2013, the American performed on the same date service: Medical Association’s (AMA) of service. Time spent for For psychotherapy services Current Procedural Terminology the E&M service is separate provided without an E&M service, (CPT) made major changes to from the time spent providing the correct code depends on the CPT codes for Psychiatry and psychotherapy and time spent time spent with the beneficiary. Psychotherapy Services. providing psychotherapy cannot be used to meet criteria Main Error: The main error • 90832: Psychotherapy, 30 for the E&M service. that CERT has identified with minutes with patient and/or family member. the revised psychiatry and Because time is indicated in psychotherapy codes is not clearly the code descriptor for the • 90834: Psychotherapy, 45 documenting the amount of time psychotherapy CPT codes, it is minutes with patient and/or spent only on psychotherapy important for providers to clearly family member. services. The correct Evaluation document in the patient’s medical • 90837: Psychotherapy, 60 and Management (E&M) code record the time spent providing the minutes with patient and/or selection must be based on the psychotherapy service rather than family member. elements of the history and exam entering one time period including and medical decision making the E&M service. In general, select the code required by the complexity/intensity that most closely matches the of the patient’s condition. The New Add-on Codes: actual time spent performing psychotherapy code is chosen on • +90833: Psychotherapy, 30 psychotherapy. CPT provides the basis of the time spent providing minutes with patient and/ flexibility by identifying time ranges psychotherapy. or family member when that may be associated with each of the timed codes: • When a beneficiary receives performed with an E&M service (list separately in an E&M service with a • 90832: 16 to 37 minutes addition to the code for primary psychotherapeutic service on • 90834: 38 to 52 minutes the same day, by the same procedure). • 90837: 53 minutes or longer provider, both services are • +90836: Psychotherapy, 45 payable if they are significant minutes with patient and/ Do not bill psychotherapy codes and separately identifiable and or family member when for sessions lasting less than billed using the correct codes. performed with an E&M 16 minutes. • New add-on codes (in the service (list separately in bulleted list below) designate addition to the code for primary Psychotherapy codes are no longer psychotherapeutic services procedure). dependent on the service location performed with E&M codes. An • +90838: Psychotherapy, 60 (i.e., office, hospital, residential add-on code (often designated minutes with patient and/ setting, or other location is not a with a “+” in codebooks) or family member when factor). However, effective January 1, 2014, when E&M services are

1 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 paid under Medicare’s Partial spent providing psychotherapy encounter. Additional requests Hospitalization Program (PHP) and services. Additional requests for for the physician’s documentation not in the physician office setting, the physician’s documentation of this information were made the CPT outpatient visit codes supporting the time spent in the and an addendum to the record 99201-99215 have been replaced psychotherapy encounter and for (dated seven months after the with one Level II HCPCS code - the psychotherapy maneuvers date of service) was received. G0463. Further information about provided on the billed date of The additional information did not this code can be found in the CY service did not result in any contain specific goals or a treatment 2014 OPPS/ASC final rule that was other documentation. The CERT plan. The CERT reviewer scored published in the Federal Register reviewer scored this claim as an the psychotherapy service as an on December 10, 2013. overpayment due to insufficient overpayment due to insufficient documentation and the Medicare documentation and the MAC Insufficient Documentation Administrative Contractor (MAC) recouped the payment from Causes Most Improper recouped the payment from the provider. Payments. the provider. Insufficient documentation means Example 4: Insufficient that something was missing from Example 2: Insufficient Documentation. A Professor of the medical records. For example, Documentation. A Psychiatry (physician) billed for there was: neuropsychiatrist (physician) billed a level 3 E&M service (99213) for a level 4 E&M service (99214) and 45 minutes of psychotherapy • No documentation of the and 60 minutes of psychotherapy (90836). Detailed office notes that amount of time spent with the (90838). An office visit note supported both the E&M service patient (length of the session); was provided that included this and psychotherapy services • No documentation of statement, “…more than 50% of were provided. However, the modalities of treatment the time was spent in counseling documentation stated “35 minutes furnished (e.g., cognitive or coordination of care. This visit of cognitive-behavior therapy.” restructuring, behavior lasted 60 minutes.” No other The code was changed to 90833, modification) to effect documentation was submitted. which indicates 30 minutes with improvement; Specifically, the psychotherapy patient and/or family member when • No documentation of progress service documentation did not performed with an evaluation and to date; and indicate the time in minutes, and management service. The CERT the documentation submitted did reviewer scored the psychotherapy • No updated treatment plan. not adequately describe the service service as an overpayment due to Examples of Improper defined by the HCPCS code a service incorrectly coded and the Payments for Psychiatry and billed. The CERT reviewer scored MAC adjusted the payment. Psychotherapy Services the psychotherapy service as an overpayment due to insufficient Resources: You can find more Example 1: Insufficient documentation. The MAC recouped information on how to avoid errors documentation and no additional the payment from the provider. on claims for psychiatric and documentation received. A psychotherapy services in the geriatric psychiatrist (physician) Example 3: Insufficient following: billed for a level 3 E&M service Documentation. A psychiatrist (99213) and 45 minutes of (physician) billed for a level 5 • Local Coverage Determinations psychotherapy (90836). A print out E&M service for a new patient (LCDs), which are available from an electronic health record (99205) and 60 minutes of at http://www.cms.gov/ showed an authenticated visit note psychotherapy (90838). The Medicare/Coverage/ indicating total face to face time documentation submitted for DeterminationProcess/LCDs. of 45 minutes. The record did review did not include the amount html on the CMS website; not separately indicate the time of time spent in the psychotherapy

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 2 • Current Procedural • Add-on HCPCS/CPT Codes Terminology (CPT) 2014. without Primary Codes - MLN (Refer to page xxiv (E/M Matters Number: SE1320, Did you know... and Psychotherapy Coding revised August 16, 2013, Algorithm) of the 2014 CPT and available at http:// Professional Edition in www.cms.gov/Outreach- Looking for the latest new and revised choosing the appropriate and-Education/Medicare- MLN Matters® articles? Subscribe to psychotherapy codes); Learning-Network-MLN/ the MLN Matters® electronic mailing • Federal Register, December MLNMattersArticles/ list! For more information about MLN Matters® and how to register 10, 2013, Table 42. CY Downloads/SE1320.pdf on the CMS website; and for this service, go to http://www. 2013 Clinic and Emergency cms.gov/Outreach-and-Education/ Department Visit HCPCS • Medicare Program Integrity Medicare-Learning-Network-MLN/ Codes and APC Assignments Manual, Section 3.3.2.5 – MLNProducts/downloads/What_Is_ Compared to CY 2014 Clinic Amendments, Corrections and MLNMatters.pdf and start receiving and Emergency Department Delayed Entries in Medical updates immediately! Visit HCPCS Codes and APC Documentation, available Assignments. p. 75042 – at http://www.cms.gov/ 75043; Regulations-and-Guidance/ • Federal Register, November Guidance/Manuals/ 15, 2012, Table 42. Crosswalk Downloads/pim83c03.pdf on of Deleted and New PHP CPT the CMS website. and HCPCS Billable Codes for 2013 p. 68416; • The CERT Provider Website, available at https://www. certprovider.com, has a menu option for Psychotherapy Claims; • Psychotherapy Notes - MLN Matters® Number MM 3457, revised February 4, 2013, and which is available at http://www.cms.gov/ Outreach-and-Education/ Medicare-Learning-Network- MLN/MLNMattersArticles/ downloads/mm3457.pdf on the CMS website;

3 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 Comprehensive Error Rate Testing (CERT): Computed Tomography (CT) Scans

Provider Types Affected: Hospitals, physicians, and other providers billing for CT scans and services.

Background: The CERT documentation must include reporting of a CT scan of the head/ review contractor determined relevant medical history, pertinent brain without contrast, HCPCS that Medicare made improper physical examination, diagnosis 70450. The CERT reviewer payments on CT scan claims (if known), and results of pertinent received a typed report of the submitted for payment from July diagnostic tests and /or procedures. results of the CT scan, without 2011 through June 2012. CT scans While a signature on the physician a signature. The CERT reviewer had an improper payment rate of order is not required, the physician made additional requests for 16 percent during this period. must clearly document, in the documentation but did not receive medical record, his or her intent to a signed report. The CERT Insufficient Documentation have the test performed. reviewer did not receive an order Causes Most Improper Payments from the treating physician, nor Insufficient documentation Examples of Improper Payments did they receive progress notes caused more than 99 percent of for CT Scans to support the treatment plan or the improper payments. Missing intent to order the CT scan or a Example 1: No documentation orders caused over half of the reason for ordering the CT scan. received for a CT scan head/ insufficient documentation errors. After the due date for submitting brain. A diagnostic radiologist Insufficient documentation means documentation passed, the CERT (physician) billed for professional that something was missing from reviewer received a duplicate services for interpretation and the medical records. For example, report of the results of the CT reporting of a CT scan of the there was: scan with a signature added (i.e., head/brain without contrast, an altered document). Although • No record of the billed service; Healthcare Common Procedure the CERT review contractor can Coding System (HCPCS) 70450. • No order or no evidence of accept a signature attestation for The provider sent a checklist intent to order; documents other than orders or stating, “There is no record of • No physician’s signature on the certifications, the CERT cannot patient receiving treatment at order and no signature log or accept altered documents. The this facility.” The CERT reviewer attestation; and /or CERT reviewer scored this claim as made additional requests for an overpayment due to insufficient • No results of a diagnostic test. documentation but did not documentation and the MAC receive a radiology report nor did Avoid Errors by Attending to recouped the payment from they receive a medical record Documentation Requirements the provider. to support the intent to order Medicare’s National Coverage the CT scan or the medical Determination (NCD) on Computed Example 3: Insufficient necessity for the billed service. Tomography (NCD 220.1) Documentation for a CT scan The CERT reviewer scored this states that CT scans must be abdomen/pelvis. A diagnostic claim as an overpayment due to medically appropriate considering radiologist (physician) billed no documentation and the MAC the patient’s symptoms and for professional services for recouped the payment from preliminary diagnosis. Local interpretation and reporting of a CT the provider. Coverage Determinations (LCDs) scan of the abdomen/pelvis without contrast, HCPCS 74176. The for CT scans further define the Example 2: Insufficient CERT reviewer received a report circumstances demonstrating Documentation for a CT scan of the results of the CT scan with medical necessity and require head/brain. A diagnostic radiologist a notation on the report “Signed that documentation is available (physician) billed for professional copy of report in Medical Imaging” to Medicare upon request. The services for interpretation and

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 4 but there was no signed report • LCDs, available at http://www. submitted. The CERT reviewer cms.gov/Medicare/Coverage/ made additional requests for DeterminationProcess/LCDs. documentation but did not receive a html on the CMS website; Did you know... physician’s order for the CT scan or • Medicare Coverage of Imaging evidence of the physician’s intent to Services Fact Sheet, available order the CT scan or documentation at http://www.cms.gov/ Although the final rule on the proposed of the medical necessity for the CT Outreach-and-Education/ ICD-10 deadline change has yet to be scan. The CERT reviewer scored Medicare-Learning- published, it is important to continue this claim as an overpayment due planning for the transition to ICD- Network-MLN/MLNProducts/ 10. The switch to the new code set to insufficient documentation and downloads/Radiology_ will affect every aspect of how your the MAC recouped the payment FactSheet_ICN907164.pdf on organization provides care, but with from the provider. the CMS website; and adequate planning and preparation, you can ensure a smooth transition for your Example 4: Insufficient • Important Reminders about practice. Keep Up to Date on ICD-10. Documentation for a CT scan Advanced Diagnostic Please visit the ICD-10 website for the Imaging (ADI) Accreditation latest news and resources to help you thorax. A diagnostic radiologist prepare. (physician) billed for professional Requirements - MLN Matters® services for interpretation and Article SE1122, revised July reporting of a CT scan of the 31, 2012, available at http:// thorax (chest) without contrast, www.cms.gov/Outreach- HCPCS 71250. The CERT reviewer and-Education/Medicare- received a report of the results of Learning-Network-MLN/ the CT scan but received no other MLNMattersArticles/ documentation despite additional Downloads/SE1122.pdf on requests. There was no order the CMS website. from a treating physician and no documentation to support the intent to order the scan or documentation of the medical necessity for the CT scan. The CERT reviewer scored this claim as an overpayment due to insufficient documentation and the MAC recouped the payment from the provider.

Resources: You can find more information on how to avoid errors on claims for diagnostic tests at:

• National Coverage Determination 220.1 – Computed Tomography (Effective March 12, 2008), available at http://www.cms. gov/medicare-coverage- database/overview-and- quick-search.aspx on the CMS website;

5 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 Comprehensive Error Rate Testing (CERT): Preventive Services

Provider Types Affected: Physicians, hospitals, and other providers billing for preventive services

Background: According to Section payment from July 2012 through Examples of Improper Payments 1861(ddd) of the Social Security Act September 2012. for Preventive Services (the Act), CMS may add coverage Here are three examples of of "additional preventive services" • Screening and Behavioral improperly billed preventive through the National Coverage Counseling Interventions services. Determination (NCD) process if all in Primary Care to Reduce of the following criteria are met. The Alcohol Misuse; Example 1: G0442 Annual preventive service must be: • Annual Alcohol Misuse Alcohol Misuse Screening, Screening, 15 minutes 15 Minutes 1. reasonable and necessary (G0442); A provider billed for annual alcohol for the prevention or early misuse screening, 15 minutes. • Brief Face-to-Face Behavioral detection of illness or disability; Medical records documented that Counseling for Alcohol Misuse, the beneficiary was 24 years sober. 2. recommended with a grade 15 minutes (G0443); of A or B by the United States The provider did not document • Annual Depression Screening, screening for alcohol misuse. Preventive Services Task 15 minutes (G0444); and Force (USPSTF); and There was no evidence of the • Annual, Face-To-Face 5A approach (Assess, Advise, 3. appropriate for individuals Intensive Behavioral Therapy Agree, Assist, and Arrange) as entitled to benefits under Part For Cardiovascular Disease, described in the NCD on Screening A or enrolled under Part B of Individual, 15 minutes (G0446). and Behavioral Counseling the Medicare Program. Interventions in Primary Care Findings: The improper payment Medicare covers preventive to Reduce Alcohol Misuse. The rates for these four preventive services only when specifically provider did not document any services ranged from 22 percent covered in an NCD, or in statute. time spent performing screening to 46 percent. The CERT CMS reviewed the USPSTF’s “B” for alcohol misuse. The CERT review contractor determined recommendations and supporting reviewer contractor scored this that insufficient documentation evidence and determined that the claim as an overpayment due to causes most improper payments. following preventive services meet insufficient documentation and the Insufficient documentation means the criteria for coverage: MAC recouped the payment from that something was missing from the provider. • Screening and Behavioral the medical records. For example, Counseling Interventions there is: Example 2: G0444 Annual in Primary Care to Reduce Depression Screening, • No record of the amount of Alcohol Misuse; 15 minutes time spent providing a timed A provider billed for annual • Screening for Depression in service; Adults; and depression screening, 15 minutes. • No record of the billed service; The provider did not document • Intensive Behavioral Therapy or screening for depression and for Cardiovascular Disease. • No physician’s signature on the did not document any time Improper Payments for medical record. spent performing screening for Preventive Services depression. The CERT review The CERT review contractor contractor made an additional studied claims for the following four request for documentation and preventive services submitted for received a Geriatric Depression

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 6 Scale questionnaire for a date Guidance: How Providers Can • Quick Reference Information: of service that did not match Avoid These Problems Preventive Services, which is the sampled claim. The CERT available at http://www.cms. reviewer scored this claim as an Providers should: gov/Medicare/Prevention/ overpayment due to insufficient PrevntionGenInfo/ ✓Record start and stop times, documentation and the MAC ✓ Downloads/MPS_ or the total time spent, when recouped the payment from QuickReferenceChart_1.pdf providing a timed service; the provider. on the CMS website; ✓Sign entries in medical records • Prevention – General Example 3: Annual, Face-To-Face ✓ at the time of service; and Information, available at Intensive Behavioral Therapy http://www.cms.gov/ for Cardiovascular Disease, ✓✓Learn about the non-covered Medicare/Prevention/ Individual, 15 minutes (G0446) indications and frequency limits PrevntionGenInfo/ on the A provider billed for annual, for preventive services. CMS website; face-to-face intensive behavioral therapy for cardiovascular disease, Providers should know that: • Medicare National Coverage individual, 15 minutes. The provider Determinations, available submitted a physician’s progress ✓✓Screening for depression is at http://www.cms.gov/ note with an illegible signature for non-covered when performed medicare-coverage- the date of service. The CERT more than one time in a database/overview-and- reviewer also received a preventive 12-month period; quick-search.aspx on the care flow sheet, a depression exam, CMS website, especially: ✓Alcohol screening is non- a nutrition exam, and a mini mental ✓ ––Section 210.8 – Screening covered when performed more status exam. This documentation and Behavioral Counseling than one time in a 12-month did not include the amount of time Interventions in Primary Care period; spent on counseling. The CERT to Reduce Alcohol Misuse reviewer made an additional (Effective October 14, 2011); ✓✓Brief face-to-face behavioral request for documentation and counseling interventions are ––Section 210.9 – Screening received a signature attestation non-covered when performed for Depression in Adults and signature log. The provider more than once a day; that is, (Effective October 14, 2011); sent an unsigned late entry in two counseling interventions on ––Section 210.11 – Intensive the margin of the medical record, the same day are non-covered; Behavioral Therapy for dated three months after the date and Cardiovascular Disease of service, which showed the time (CVD) (Effective November 8, ✓ spent on counseling. Amendments, ✓ Brief face-to-face behavioral 2011); and corrections and delayed entries in counseling interventions are • "Medicare Program Integrity medical documentation must be non-covered when performed Manual," Section 3.3.2.5 – clearly signed and dated upon entry more than four times in a Amendments, Corrections and into the record per section 3.3.2.5 12-month period. of the Program Integrity Manual. Delayed Entries in Medical The CERT reviewer scored this Resources: Documentation at http://www. claim as an overpayment due to You can find more information on cms.gov/Regulations-and- insufficient documentation and the how to avoid errors on claims for Guidance/Guidance/Manuals/ MAC recouped the payment from preventive services via following Downloads/pim83c03.pdf on the provider. resources: the CMS website.

7 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 Recovery Audit Finding: Durable Medical Equipment (DME) Group 2 – Pressure Reducing Support Surfaces

Provider Types Affected: DME suppliers

Background: According to the • The beneficiary has large or Example 1: Documentation Office of Inspector General (OIG) multiple stage III or IV pressure does not support coverage. report and the DME MACs medical ulcer(s) on the trunk or pelvis 86 year old female received home review results, a large majority of (ICD-9 707.02-707.05). health care for wound care and claims billed for Group 2 – Pressure • The beneficiary had a regular assistance with personal Reducing Support Surfaces did not myocutaneous flap or skin hygiene. The patient was home meet Medicare’s clinical coverage graft for a pressure ulcer on bound due to decreased endurance requirements, or did not meet the trunk or pelvis within the related to muscle weakness and Medicare supplier’s documentation past 60 days (ICD-9 707.02 shortness of breath, ambulated with requirements. -707.05), and has been on a use of a cane, and suffered from group 2 or 3 support surface diarrhea with fecal incontinence, Local Coverage Determination immediately prior to discharge urinary incontinence, and insulin- (LCD) L27009 for Group 2 – from a hospital or nursing dependent diabetes. On 1/29/08 Pressure Reducing Support facility within the past 30 days. the initial staff nurse (SN) wound Surfaces Effective 10/1/1993, evaluation documented one revised 1/1/2011, this LCD states If the beneficiary is on a Group 2 pressure ulcer of the right buttock, that a Group 2 support surface is surface, there should be a care 1.5 cm x 0.5 cm x 0 cm depth, covered if the beneficiary meets plan established by the physician Stage I, with no exudate. The air at least one of the following or home care nurse that includes treatment mattress E0277 was three criteria: the above elements. The support delivered 2/1/08, based on a surface provided for the beneficiary 1/30/08 physician’s prescription, • The beneficiary has multiple should be one in which the which stated the patient had 3 stage II pressure ulcers beneficiary does not "bottom out." Stage II pressure ulcers of the located on the trunk or pelvis buttocks and coccyx and had been (ICD-9 707.02-707.05) which When the stated coverage criteria receiving care for the ulcers for have failed to improve over for a Group 2 mattress or bed are at least one month. The next SN the past month, during which not met, a claim will be denied as evaluation of the same wound on time the beneficiary has been not reasonable and necessary. 2/7/08 documented the wound on a comprehensive ulcer measured 1.3 cm x 0.5 cm x 0 cm treatment program including Continued use of a Group 2 support depth, Stage 1, with no exudate. all of the following: ( a.) Use surface is covered until the ulcer On 3/3/08, the SN documented the of an appropriate group 1 is healed, or if healing does not patient had one Stage II pressure support surface, ( b.) Regular continue, there is documentation ulcer of the sacrum measuring 1 cm assessment by a nurse, in the medical record to show that: x 1 cm x 0.1 cm. On 5/16/08 the SN physician, or other licensed (1) other aspects of the care plan noted the patient "...has a pressure healthcare practitioner, (c.) are being modified to promote sore on right side of buttocks, Appropriate turning and healing, or (2) the use of the group pressure area is not open at this positioning, ( d.) Appropriate 2 support surface is reasonable and time but still has a red area," and a wound care, (e.) Appropriate necessary for wound management. thorough SN note of 9/22/08 did not management of moisture/ mention any pressure ulcer. incontinence, and Recovery Auditor Findings: Here are two examples where use of (f.) Nutritional assessment and Finding: The documentation does DME Group 2 pressure reducing intervention consistent with the not support coverage of the Group support surfaces was not supported overall plan of care. 2 pressure reducing support surface by the documentation. per NGS LCD L27009.

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 8 Example 2: Documentation Finding: The documentation does • "National Coverage does not support coverage. not support coverage of the Group Determinations Manual," 82 year old male was admitted to 2 pressure reducing support surface Chapter 1, Part 4, Section a Skilled Nursing Facility (SNF) per National Government Service 280.1, Durable Medical from a hospital stay on 7/17/08 (NGS) LCD L27009. Equipment Reference List, with a diagnosis of urosepsis and Alternating Pressure Pads, cerebrovascular accident (CVA) Guidance: How Providers Can Mattresses and Lamb’s Wool with right-sided weakness. The Avoid These Problems Pads is available at http://www. patient had a Foley catheter; sliding cms.gov/Regulations-and- ✓DME suppliers and scale insulin for blood glucose ✓ Guidance/Guidance/Manuals/ practitioners should review and management. The patient was Downloads/ncd103c1_Part4. follow the clinical requirements initially bed- and wheelchair- bound pdf on the CMS website. supporting medical necessity and required maximum assistance of pressure reducing support • NGS Jurisdiction B Supplier to turn and transfer, progressing surfaces, as specified in NGS Manual, Chapter 8 – to walking with Physical Therapy LCD L27009. Both ordering Documentation, is available at assistance 5 feet. Upon admission practitioners and DME http://www.ngsmedicare.com/ the patient was noted to have Stage suppliers should follow medical ngs/portal/ngsmedicare/ on I and II pressure ulcers of coccyx; necessity guidelines to prevent the Internet. on 7/21/08 the nurse documented overpayments. • "Medicare Benefit Policy Stage II wound to the coccyx was Manual," Chapter 15, Covered clean, dry, and open to air. On Resources: Medical and Other Health 7/23/08 and 7/24/08, the staff noted Services, Section 100 – barrier cream was applied to his • August 2009 OIG Report OEI- Durable Medical Equipment Stage II coccyx wound and left 02-07-00420 – "Inappropriate – General is available at http:// open to air. The patient received Medicare Payments for www.cms.gov/Regulations- nutritional support with a thickened Pressure Reducing Support and-Guidance/Guidance/ diet. Documentation made no Surfaces," available at http:// Manuals/Downloads/ reference to any pressure reducing oig.hhs.gov/oei/reports/oei- bp102c15.pdf on the surface used during the SNF stay. on 02-07-00420.pdf CMS website. He was discharged home with the Internet. • "Program Integrity Manual home health care on 7/30/08. The • NGS LCD L27009 for Pressure (PIM)," Chapter 5 – Items and initial home health SN evaluation Reducing Support Surfaces – Services Having Special DME on 7/31/08 documented one Stage Group- 2 Effective 10/1/1993, Review Considerations, Section III pressure ulcer of the buttock revised 1/1/201, is available at measuring 11.0 cm x 10.0 cm x 0.1 5.2.3 – 5.2.3.1, Detailed Written http://apps.ngsmedicare.com/ Orders and Written Orders Prior cm depth with granulating wound applications/Content.aspx?D to Delivery is available at http:// bed and no drainage; no treatment OCID=21678&CatID=3&RegID www.cms.gov/Regulations- or plan of care was submitted with =51&ContentID=34527 on and-Guidance/Guidance/ record. The powered pressure the Internet. reducing air mattress E0277 Manuals/Downloads/ • NGS Report "Widespread was delivered on 8/1/08, and the pim83c05.pdf on the Prepayment Probe for Pressure physician’s prescription of the same CMS website. Reducing Support Surfaces date stated the patient had multiple HCPCS E0277", revised Stage II pressure ulcers of both the 11/22/10, is available at http:// lower back and buttocks, which had www.ngsmedicare.com/ngs/ received treatment for at least the portal/ngsmedicare/ on past month. the Internet.

9 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 Recovery Audit Finding: Group 2 Power Wheel Chairs

Provider Types Affected: Durable Medical Equipment (DME) Suppliers

Problem Description: Recovery 4. Pertinent diagnoses/conditions • Product description: If the Auditors identified Group 2 that relate to the need for a detailed product description portable wheelchairs as a source of PMD; for the specific device is not overpayments. The Local Coverage 5. Length of need; obtained prior to delivery, Article (LCD) A41127 provides payment will not be made the following information about 6. Physician’s signature; and for the item even if the the medical necessity for Group 2 7. Date of physician’s signature. documentation is subsequently portable wheelchairs. obtained. If a similar item It is a statutory requirement that all is provided by an unrelated Power mobility devices are items of the seven-element order be supplier who has obtained the covered under the Durable Medical entered specifically by and only by required documentation prior to Equipment benefit (Social Security the practitioner who has conducted delivery, it will be eligible Act, Section1861(s)(6)). In order the face-to-face requirements for coverage. for a beneficiary’s equipment to (see below). A power mobility • Face-to face Examination: be eligible for reimbursement, the device may not be ordered by a For a POV or PWC to be reasonable and necessary (R&N) podiatrist. If it is, it will be denied covered, the treating physician requirements set out in the related as noncovered. must conduct a face-to-face Local Coverage Determination examination of the beneficiary must be met. • Supplier requirements: For before writing the order and the a power operated vehicle supplier must receive a written • Physician’s Orders: The (POV) or power wheelchair report of this examination Medicare Prescription (PWC) to be covered, the within 45 days after completion Drug, Improvement, and supplier must receive from the of the face-to-face examination Modernization Act of 2003, treating physician a written and prior to delivery of the added section 1834(a)(1) order, termed the seven- device. If this requirement (E)(iv) which provides that element order, containing all is not met, the claim will payment may not be made for a the elements specified in the be denied as noncovered. motorized or power wheelchair Documentation Requirements (Exceptions: If this examination unless the practitioner who section of the Local Coverage is performed during a hospital has conducted the face-to-face Determination within 45 or nursing home stay, the examination him or herself days after completion of supplier must receive the writes the seven-element order: the physician’s face-to- report of the examination within face examination and prior 45 days after discharge.) 1. Beneficiary’s name; to delivery of the device. 2. Description of item that is (Exception: If the examination The physician may refer the ordered; (This description is performed during a hospital beneficiary to a licensed/certified may be general (for example, or nursing home stay, the medical professional (LCMP), “power operated vehicle,” supplier must receive the order such as a physical therapist (PT) “power wheelchair,” or within 45 days after discharge.) or occupational therapist (OT), “power mobility device”) If these requirements are not who has experience and training in or more specific.) met, the claim will be denied mobility evaluations to perform part 3. Date of completion of the face- as noncovered. of the face-to-face examination. to-face examination; This person may have no financial relationship with the supplier.

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 10 (Exception: If the supplier is owned a written signed and dated delivered to the patient; Document by a hospital, PT or OT working in order must be received by the Request letter from Recovery the inpatient or outpatient hospital supplier prior to delivery of the Auditor; duplicate copies of the setting may perform part of the item. If the supplier delivers the physician progress notes and a two face-to-face examination.) item prior to receipt of a written page MRI lumbar spine report. If the beneficiary was referred order, it will be denied as before being seen by the physician, noncovered. If the written order Supplier Documentation: Two then once the physician has is not obtained prior to delivery, pages of photocopies of Medicare received and reviewed the written payment will not be made for and AARP cards; wheelchair report of this examination, the that item even if a written order warranty; the purchase option physician must see the beneficiary is subsequently obtained. If a provided to the patient; proof of and perform any additional similar item is subsequently delivery signed by the patient examination that is needed. The provided by an unrelated on March 25, 2010; an undated report of the physician’s visit supplier who has obtained a one page home assessment; an shall state concurrence or any written order prior to delivery, it information form on the power disagreement with the LCMP will be eligible for coverage. wheelchair and an intake form. examination. In this situation, the Face-to face evaluation: physician must provide the supplier Examples: Here are two examples Not present. with a copy of both examinations of erroneous billing for Group 2 portable wheelchairs. within 45 days after the face-to-face Physician Order: Did not contain examination with the physician. Example 1: Insufficient all seven elements. documentation to support the If the physician saw the beneficiary Detailed product description: claim. An 84 year old female to begin the examination before Not present. referring the beneficiary to an received a Group 2 power LCMP, then if the physician sees wheelchair (Healthcare Common Home assessment: Inadequate. the beneficiary again in person Procedural Coding System after receiving the report of the (HCPCS) code K0823, standard, Proof of Delivery: Adequate. LCMP examination, the 45-day captain’s chair, power wheelchair, period begins on the date of that patient capacity up to and including second physician visit. However, it 300 pounds) on March 25, 2010. is also acceptable for the physician The patient weighed 146 pounds. to review the written report of Diagnoses to support indication: the LCMP examination, to sign Spinal stenosis, right ankle and date that report, and to state tendonitis, back pain, lower concurrence or any disagreement extremity weakness. with that examination. In this situation, the physician must send a Physician documentation: A copy of the note from his/her initial pre-printed physician order form visit to evaluate the beneficiary plus signed by the physician on March the annotated, signed, and dated 19, 2010; five pages of physician copy of the LCMP examination to progress notes dated March 9 to the supplier. The 45-day period March 18, 2010, none of which begins when the physician signs were mobility related. A letter and dates the LCMP examination. addressed “To Whom It May Concern,” dated March 2, 2012, • Signed, dated order: For an discussing the need for the power item addressed in this policy wheelchair, which was dated two to be covered by Medicare, years after the wheelchair was

11 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 Finding: The Recovery Auditor Physician documentation: Order Physician’s Order: Did not indicate denied the claim because: for power wheelchair date June 17, date of face-to face evaluation. 2010; Face-to-face examination • The claim lacked dated July 1, 2010; physician Detailed product description: documentation of a face- progress note dated June 30, 2010; Not present. to-face examination by the and physical therapy note dated Home Assessment and proof of physician to establish June 14, 2010. medical necessity; delivery: Adequate. Supplier documentation: Home • The remaining physician’s Finding: The Recovery Auditor assessment date July 19, 2010; documentation lacked denied the claim because: essential, detailed, descriptive, proof-of delivery dated July 19, objective information 2010; a purchase option and • Documentation did not support addressing the patient’s Health Insurance Portability and that the power wheelchair mobility limitations; Accountability Act (HIPPA) form was medically necessary and both dated July 19 2010; and • The supplier did not provide a reasonable because it lacked policy report dated March 31, detailed product description; detailed, descriptive, objective 2010. The police report indicated and information addressing the that the patient walked into the patient’s mobility limitations; • The home assessment did interview room with the assistance • Information in the face- not indicate that the power of a walker. According to the to-face examination form, wheelchair would be able to patient, his scooter stopped on physical therapy evaluation access the rooms in the home his way home from errand. He and the police report provided required to perform activities of managed to get the scooter into conflicting pictures of daily living (ADLs). some shrubbery so that it was the patient; out of sight. He called a cab and Example 2: Errors in went home. When he went back to • The physician’s order was documentation and retrieve the scooter, it was gone. written 14 days before the documentation did not support face-to-face examination. medical necessity. A 68 year old Face-to-face examination: • The physician’s order did not male received a Group 2 power Physician indicated patient was to contain all the required wheelchair (HCPCS code K0823, receive a scooter; however, this seven elements; and standard, captain’s chair, power was crossed out and there was a • Documents lacked a detailed wheelchair, patient capacity up to “POW” in its place. Face-to face description of the product. and including 300 pounds) on July was completed 14 days after the 19, 2010. The patient weighed physician wrote the order. Stated Guidance: How Providers Can 246 pounds. Patient previously the patient has poor balance but no Avoid These Problems: had a scooter which was stolen. history of falls, poor endurance, but no weakness. Patient used walls ✓The provider should seek Diagnoses to support indication: ✓ and furniture for mobility. States guidance and education Coronary artery disease (CAD), patient was unable to perform regarding the medical Congestive heart failure (CHF), activities of daily living due to back necessity policies regarding diabetes mellitus (DM), and pain. Walker or cane would not Group 2 Power Wheelchairs. degenerative disc disease (DDD), allow activities of daily living (ADLs) Also understand the role of abnormality of gait, asthma, to be performed in a timely manner. physician documentation and dyspnea, obesity, lumbago, Caregiver was unable to provide the responsibility to provide numbness, malaise, osteoarthritis, assistance for manual wheelchair, economical and medically sleep apnea and vision problems. but there was no indication as necessary care and equipment.

to why. Reviewing the resources listed below is a good start

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 12 to understanding the policies • MLN Matters® Article for ordering Group 2 Power Number SE1112, Power Wheelchairs. Contact the Mobility Device Face-to- DME Medicare contractor Face Examination Checklist, Did you know... for further information and dated 5/2/2011, is available educational events. at http://www.cms.gov/ In order for Medicare to cover a power Additional Resources: Outreach-and-Education/ mobility device (PMD), the supplier must receive the written prescription Medicare-Learning-Network- • The Power Mobility Devices within 45 days of a face-to-face MLN/MLNMattersArticles/ examination by the treating physician, Fact Sheet is available at Downloads/SE1112.pdf on or discharge from a hospital or https://www.cms.gov/ the CMS website. nursing home, and before the PMD Outreach-and-Education/ is delivered. The date of service on • The "Medicare Benefit Policy Medicare-Learning- the claim must be the date the PMD Manual," Chapter 15, Section Network-MLN/MLNProducts/ device is furnished to the patient. A 110.2, is available at http:// PMD cannot be delivered based on downloads/PMD_DocCvg_ www.cms.gov/Regulations- a verbal order. If the supplier delivers FactSheet_ICN905063.pdf on and-Guidance/Guidance/ the item prior to receipt of a written the CMS website. prescription, the PMD will be denied Manuals/Downloads/ as non-covered. • The "Medicare National bp102c15.pdf on the Coverage Determinations CMS website. For more details, please refer to Manual," section 280.3, is the Medicare Learning Network® available at http://www. fact sheet on this topic titled, cms.gov/Regulations-and- “Power Mobility Devices (PMDs): Complying with Documentation & Guidance/Guidance/Manuals/ Coverage Requirements.” Downloads/ncd103c1_Part4. pdf on the CMS website. • Local Coverage Article for Power Mobility Devices (A41127) is available at http:// www.cms.gov/medicare- coverage-database/details/ article-details.aspx?articleId= 41127&ver=28&ContrId=139& ContrVer=2&CntrctrSelected= 139*2&Date=&DocID=A41127 &bc=hAAAAAgAAAAAAA%3 d%3d& on the CMS website. • DME Supplier’s Manual, Chapter 3, Documentation Requirements, is available at https://www. noridianmedicare.com/dme/ news/manual/chapter3.html on the Internet.

13 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 Recovery Audit Finding: Multiple Surgery Reduction Errors: Single Line Modifier 51 Underpayments

Provider Types Affected: Part B Professional Services

Problem Description: Multiple Finding: The billing error resulted surgeries are separate procedures in an underpayment of $669.25. performed on the same patient at the same operative session or on Example 2: Erroneous coding Did you know... the same day for which separate leads to billing error. Physician billed one procedure with HCPCS payment may be allowed. When The Medicare Learning Network® multiple surgical procedures are code 47120 (Partial removal of (MLN) Product Ordering System performed, Medicare Physician liver) and modifier 51 (Multiple was recently upgraded to add new Fee Schedule (MPFS) rules Procedures) for date of service enhancements. You can now view an state that the second and any 06/25/2012. No other physician image of the product and access its services were billed for this date of downloadable version, if available, subsequent procedures are before placing your order. To access subject to reduced reimbursement. service. a new or revised product available for Providers are instructed to report order in hard copy format, go to MLN Finding: The billing error resulted in modifier 51 (multiple procedures) Products and click on “MLN Product an underpayment of $1,230.47. to identify such services. When Ordering Page” under “Related Links” at the bottom of the web page. only one surgical procedure is Guidance: How Providers Can performed and modifier 51 is Avoid These Problems claimed, the reimbursement is inappropriately reduced by 50%. ✓✓Providers and their billing This concept was identified as representatives must use a result of research and data caution when using modifier analysis of the Centers for 51. It is inappropriate to use Medicare & Medicaid Services multiple procedure modifiers, (CMS) Part B Policy for CPT- when there is no second Surgery: codes 10021 to 69990. procedure performed. Review the resources listed below to Here are two examples of better understand the erroneous billing: billing regulations.

Example 1: Erroneous coding Resources: leads to billing error. Physician The "Medicare Claims Processing billed one procedure with Manual," Chapter 12, Section Healthcare Common Procedural 40.6, and Chapter 23, section Coding System (HCPCS) code 30, available at http://www.cms. 36475 (Endovenous ablation gov/Regulations-and-Guidance/ therapy of incompetent vein, Guidance/Manuals/Internet-Only- extremity, and modifier 51 (Multiple Manuals-IOMs-Items/CMS018912. Procedures) for date of service html on the CMS website. 8/3/2010. No other physician services were billed for this date of service.

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 14 Recovery Audit Finding: CT Scans, Trunk and Extremities, Incorrect Billing

Provider Types Affected: Physicians and other Part B professional services providers

Problem Description: The National found to be medically appropriate patient; and (2) performed on a Government Services (NGS) Local considering the patient's symptoms model of CT equipment that meets Coverage Determination (LCD) and preliminary diagnosis. the criteria in C below. Sufficient L28516 includes comprehensive information must be provided with lists of ICD-9-CM codes that Example 2a: Billed diagnosis claims to differentiate CT scans support medical necessity for X-ray does not support medical from other radiology services and computed tomography (CT) trunk necessity. Provider billed CPT to make coverage determinations. and extremity scans as noted code 71250, CT of the thorax Carefully review claims to ensure below. Potential incorrect billing w/o dye, with ICD code 789.00 that a scan is reasonable and occurred for claims billed with ICD- (abdominal pain, unspecified site) necessary for the individual patient; 9-CM codes that are not supported for date of service 9/4/2009 i.e., the use must be found to be by medical necessity. medically appropriate considering Finding: Per the NGS LCD L28516, the patient's symptoms and the billed diagnosis is not supported Here are several examples of preliminary diagnosis. reviewed billings: by medical necessity. There is no general rule that Example 2b: Correct coding Example 1: Billed diagnosis does requires other diagnostic tests to be leads to a paid claim. The provider not support medical necessity. tried before CT scanning is used. also billed CPT codes 74150-51 x Provider billed CPT code 73700-26, However, in an individual case 2 (CT abdomen w/o dye) and CPT CT upper extremity w/o dye, with the contractor's medical staff may 72192-51 x 2 (CT pelvis w/o dye) ICD code 959.9 (Injury, unspecified determine that use of a CT scan as with ICD code 789.00 (abdominal site) for date of service 8/20/2009. the initial diagnostic test was not pain, unspecified site) on the reasonable and necessary because Finding: Per the LCD, the billed same claim. it was not supported by the patient's diagnosis is not supported by symptoms or complaints stated medical necessity. Per the LCD Finding: Per the NGS LCD, the on the claim form; e.g., "periodic review rationale, CT is a form of billed diagnoses for these codes are headaches." Claims for CT scans x-ray which creates cross-section supported by medical necessity and are reviewed for evidence of abuse, images. X-ray beams pass through these line items were paid. which might include the absence the body at different angles and Medical Necessity of reasonable indications for the are then recorded by detectors and Per the "Medicare National scans, an excessive number of channeled into a computer which Coverage Determinations Manual," scans, or unnecessarily expensive produces cross sectional view Chapter 1, Part 4, section 220.1 - types of scans considering the facts in different planes. A diagnostic Computed Tomography, diagnostic in the particular cases. examination of the head and of examinations of the head (head other parts of the body performed scans) and of other parts of the Guidance on how providers by CT scanners is covered by body (body scans) performed can avoid these billing errors: Medicare if there is effective use by CT scanners are covered if of the scan for specific conditions, ✓ medical and scientific literature ✓ As noted above in the NCD if it is reasonable and necessary and opinion support the effective manual, the use of CT scans for the individual patient, and if the use of a scan for the condition, must be found to be medically scanning device is FDA approved. and the scan is: (1) reasonable appropriate considering the The use of the scan must be and necessary for the individual patient's symptoms and

15 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 preliminary diagnosis. This issue identified those CT scans that were not considered medically necessary per the ICD-9-CM codes noted in the NGS policy. Did you know...

✓✓Providers need to gain a better understanding of those Want to stay connected about the latest new and revised diagnoses that are considered Medicare Learning Network® (MLN) products and services? Subscribe to the MLN Educational Products medically necessary for electronic mailing list! For more information about the CT scans. MLN and how to register for this service, visit http://www. cms.gov/Outreach-and-Education/Medicare-Learning- ✓✓Review the resources below to Network-MLN/MLNProducts/downloads//MLNProducts_ ensure correct understanding listserv.pdf and start receiving updates immediately! of those CT scans that may be billed.

Resources: National Government Services, LCD L28516 (A48015), effective 1/1/2009 to 11/14/2011 for CT and NY (retired policy), page 4, available at http://www. ngsmedicare.com on the Internet.

Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 16 Recovery Audit Finding: Office Visits Billed for Hospital Inpatients

Provider Types Affected: Physicians and other Part B professional services providers

Problem Description: If Finding: CPT Code 99205 is the Resources: Evaluation and Management overpaid claim, with a total savings Providers should consider (E&M) Services are being of $140.87. reviewing the following resources: rendered to patients admitted to Example 2: Incorrect billing • Evaluation and Management an inpatient hospital setting, then during an inpatient stay. A 79 Services Guide is available Current Procedural Terminology year old female was admitted to a at http://www.cms.gov/ (CPT) Codes 99221-99223, hospital for inpatient level of care Outreach-and-Education/ 99231-99233 and 99238-99239 on October 23, 2012 and was Medicare-Learning- are to be used. CPT codes discharged on October 26, 2012. A Network-MLN/MLNProducts/ 99201-99215 are to be used for physician billed CPT Code 99205 Downloads/eval_mgmt_ E&M services provided in the (Office or other outpatient visit for serv_guide-ICN006764.pdf on physician's office, in an outpatient the evaluation and management of the CMS website. or other ambulatory facility. a new patient) for date of service • The "Medicare Claims This problem was identified October 24, 2012. Date of service Processing Manual," Chapter through review of previous October 24, 2012, is during the 12, Sections 30.6.9.1, 30.6.9.2 Comprehensive Error Rate Testing inpatient hospital stay and data and 30.6.10, is available (CERT) reports indicating a high analysis confirms that the patient at http://www.cms.gov/ percentage of errors on E&M was not on a leave-of-absence Regulations-and-Guidance/ services, review of Medicare from the hospital on that date. Guidance/Manuals/ Policy and Data Analysis of Finding: CPT Code 99205 is the Downloads/clm104c12.pdf on Region D data. CPT Codes overpaid claim, with a total savings the CMS website. 99201-99215-E&M Services of $185.94. If E&M services are provided in the physician's being billed for a patient in an office, in an outpatient or other inpatient hospital setting, then ambulatory facility were reviewed. hospital visit codes are to be billed. Here are two examples of errors in billing: Guidance on how providers Example 1: Incorrect billing can avoid these billing errors: during inpatient stay. An 80 ✓✓Providers and their billing year old female was admitted to a staffs should increase provider hospital for inpatient level of care education regarding the on October 17, 2012 and was correct use of evaluation discharged on October 20, 2012. A and management codes physician billed CPT Code 99205 for patients admitted to an (Office or other outpatient visit for inpatient hospital setting. the evaluation and management of Some audits are more a new patient) for date of service efficiently handled through October 18, 2012. Date of service post-pay review. Correcting October 18, 2012, is during the improper payments through inpatient hospital stay and data post-payment review both analysis confirms the patient was corrects the claim(s) identified not on a leave-of-absence from the and demonstrates accurate hospital on that date. billing practice.

17 Medicare Quarterly Provider Compliance Newsletter–Volume 4, Issue 3–April 2014 Check out CMS on:

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