May 1- CMS Claim Edit

May 1, 2013 CMS Claim Edit

by Aisha Bailey

According to CMS publication; MLN Matters Number SE 1305, MLN Matters Effective May 1, 2013 CMS will  enforce the requirement that the referring provider listed on claims must be currently enrolled in Medicare. The referring provider must also be eligible to order or refer the service being billed.

Claim edits will enforce this 2010 requirement  for the following service providers; Home Health, Part B laboratories, imaging services and durable medical equipment providers.

Take a Closer Look at the Audit Process

By Jaci Johnson, CPC, CPC-H, CPMA, CPC-I, CEMC

AAPC offers a wide selection of specialty specific exams. These allow individuals to test their skills in one particular area where they feel they have a certain level of expertise. In addition to these specialty exams there is one that allows the individual to showcase their skills across multiple specialties. The Certified Professional Medical Auditor (CPMA®) exam tests one's ability to audit various specialties as well as understand how an audit is conducted from beginning to end. How do you know when you are ready to sit for this exam? What knowledge base is needed to understand the concepts? The easiest way to approach these questions is to consider how an audit is conducted in a medical practice. From the time someone in the practice decides to request an audit until the results are tabulated and presented, there are multiple steps in the process to consider. Let's take a closer look at the audit process. In essence, let's audit an audit. The first step is the decision to perform the audit. Is this audit being performed because there is a known compliance issue, did a provider request to have his records reviewed, or is it part of an annual compliance plan? Based on the answer to this question, the scope of the audit can be determined. The scope will outline the time frame for the selection of claims to be audited. The reason for the audit also will help in deciding how many claims should be reviewed. The number of claims will vary based on whether this is a focused review that is only concerned with a specific coding issue or a baseline audit that is conducted to determine if there are any potential risk issues. Often the request for the audit will require a statistically significant number of claims to be reviewed to ensure a measure of reliability in the results. The number for the statistical sample would be based on the total number of claims within a selected period of time. Once the scope is determined and the selection process has been completed, the actual review of the documentation can begin. In addition to the supporting documentation, auditors require the claims data to reflect what was actually billed. If the audit will include the review of Evaluation and Management (E/M) codes, then the auditor should have a sound knowledge of certain concepts and have certain tools available. The auditor should have a firm grasp of all the E/M guidelines in the CPT® manual and the Medicare Documentation Guidelines, both versions. The auditor also will require a thorough understanding of any modifiers associated with E/M codes. In addition to the fundamentals of auditing the documentation to ensure proper E/M code selection, the auditor should have knowledge of "incident to" guidelines, understand the guidelines associated with Physicians at Teaching Hospitals (PATH), and know how to identify in the documentation any misuse of the guidelines. If the audit will include reviewing any surgical services, the auditor is responsible for an even greater fund of knowledge. The auditor must be skilled in maneuvering through the National Correct Coding Initiative (NCCI) to determine any misuse of bundled codes. The auditor should also be aware of any Local Coverage Decisions (LCD) that may pertain to those procedures and National Coverage Issues as determined by the Centers for Medicare & Medicaid Services. As with any coding audit, an understanding of the CPT® manual coding rules for that service is mandatory. The auditor must also understand proper use of modifiers for various surgical coding scenarios and be able to determine if the documentation can support the need for that modifier. The PATH guidelines are often a part of a surgical audit as well, and it is important that the auditor be able to recognize who is performing the service. The medicine section of the CPT® manual presents the coder with a wide variety of procedures and services. From an audit perspective, this can pose a challenge. There are no set rules that cover all those services. The auditor needs to be as well-versed with infusions as with psychiatry services or physical therapy and all things in between. The NCCI and LCD can still be useful reference tools, along with any individual guidelines found within CPT®, and of course the use of modifiers. To complete an audit it is also necessary to assess the diagnosis codes that were billed to determine if the documentation can support their use. The documentation should be compared to the code billed for correct specificity. The Official Coding Guidelines found in the ICD-9 manual should be consulted for any questions concerning coding accuracy. In addition to all the coding guidelines and CMS requirements that have been noted above, the auditor should be familiar with signature requirements and also verify proper dates of service for all services reviewed. Once the audit has been completed, the results should reflect any variances in what codes and modifiers were billed versus what the auditor determined to be the codes and modifiers based on the documentation provided. The auditor should be able to provide the resources that were used in determining the findings of the audit. What is done with the audit and how the results or findings are communicated is often determined by management in the practice. Depending on the types and severity of the variances discovered in the audit process, a decision may be made to bring in legal counsel to help determine next steps. The auditor should be familiar with the information provided by the Office of Inspector General (OIG) concerning compliance and Corporate Integrity Agreements, even though the process may be handled by a lawyer. Sometimes the audit may begin at the request of a lawyer, and the whole process is considered under attorney client privilege. This concept should be clearly identified to the auditor so that the privacy of the audit can stay intact. Performing an audit can be quite a cumbersome endeavor and is a heavy responsibility. The steps outlined here are not a comprehensive list but provide an overview of some of the considerations during the audit process and should be used as a guide when deciding to sit for the CPMA® exam. Jaci Johnson is president of Practice Integrity, Richmond, Va. She has been working in the field of medical coding and auditing for 22 years and has been a CPC®since 1994. She teaches PMCC courses and manages a national client list, providing compliance monitoring for provider documentation. Johnson was recognized as Coder of the Year for the state of Virginia in 2006. She is the past president of her local AAPC chapter and currently serves on the AAPC National Advisory Board. She can be reached atjaci@practiceintegrity.com.

Practice Management Alerts from the AMA

Practice Management Alerts

May 1: Important Medicare enrollment date  The Centers for Medicare and Medicaid Services (CMS) announced that, starting May 1, physicians who refer or order services for Medicare patients will be required to be enrolled in Medicare. Claims submitted on or after May 1 that include the name and National Provider Identifier (NPI) of a physician who referred or ordered services for a Medicare patient but who is not enrolled in Medicare will be denied. CMS had originally planned to implement this requirement in 2010, but the AMA succeeded in getting it delayed for several years, during which CMS has worked to ensure that physicians are enrolled. Physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare. CMS also has a special, shorter enrollment form for use by physicians and other health professionals who just refer and order services but do not bill Medicare directly, known as the 855-0. More information on the new edits can be found in this CMS article as well as its website. For more information on Medicare enrollment in general, please visit the AMA’s Medicare enrollment website. Was this alert helpful? Forward it to a friend, and invite them to sign up for the AMA Practice Management Alerts to receive future alerts like this one. Be an AMA member. Join the AMA today at ama-assn.org/go/membership or call (800) 262-3211 to be part of the efforts to help shape a better health care future.

You need a check up!

We check our tires, our oil, our lights, check our credit report and bank account for updates all day. We check many things all day, because we know that checking and double checking is an essential part of being prepared.


But how do you prepare for increased reimbursement or changes in payer contracts. If your not checking , You need a check up!

In addition to medical billing services we also perform comprehensive claim review and auditing which result in increased revenue and can help you streamline your practice workflow.

Give us a call to see how a check up can help you make more money.

Reimbursements, Get off at the next EXIT!

 Most small practices operate with the help of a small staff.
And most of the staff members have dual responsibilities.

Do you have a medical biller/medical assistant/receptionist/ office manager/appointment scheduler/ authorization specialist/coder/ medical records clerk/ appointment confirmer/copay collector/claims submitter..... in your office?

If you do- I have some questions for you? Who is dedicated to collecting payments from the insurance company? and more importantly who is keeping a watchful eye over the reimbursement trends to increase your revenue cycle?

There is no fault in hiring a rock star multi-tasker, but even the best needs the right tools to do their job.  And that tool is TIME.

Consider the time it takes to perform all those other important office functions vs. the time it takes to perform the most important administrative job in the practice; securing reimbursement.

By using a billing company you will be able to save your company from spending more money on paying one or more salaries, vacations, sick pay, health insurance and all the other overhead associated with hiring an in-house biller. Your existing support staff will be able to perform the best of their expertise without compromising reimbursement.

Because our billers are assigned specifically to your practice, you will have 24/7 access through our web based integrated billing/ practice management software. This will give you access to have your accounts/billing information just like the one on one transparency you would have with an in-house medical biller. And most importantly, give you TIME to focus on what's important.

We have over 25 years experience in medical billing and practice management. Along with our experience we are equipped with knowledge and access to tremendous software tools that cater to all the nuances of medical billing.

Interested?  Call or email me for a Free Billing Consultation.

abailey@mkbilling.com      www.mkbilling.com     914-226-8642

For more information please contact me directly, and I will be happy to answer any of your questions. 

Common Coding Mistakes in Ambulatory Surgery Centers: Orthopedic & Pain Management (Part 1 of 3)

Procedural coding errors can lead to lost revenue or unintentional upcoding at ambulatory surgery centers. 

Stephanie Ellis, RN, CPC, is the president and owner of Brentwood, Tenn.-based Ellis Medical Consulting, and Lolita M. Jones, RHIA, CSS, is an independent coding and billing consultant.

Here Ms. Jones and Ms. Ellis elaborate on seven trouble areas for coding orthopedic and pain management procedures.

1. Fracture debridement. Coders frequently do not recognize debridement of an open fracture, since it may be only a couple of words in the operative report. They should pay close attention to fracture care in case debridement is mentioned. If it's noted by the surgeon at all, it must be coded in addition to the fracture treatment, Ms. Jones says. The correct code to use is 11010, 11011 or 11012.

2. Tendon grafts with ACL reconstruction. The 20924 code for the harvest of a patellar or hamstring tendon graft is billable only when the graft is obtained from the opposite knee or from either ankle, Ms. Ellis says. 

The current procedural guidelines state the graft must be "from a distance" when billed with the 29888 ACL repair code, which means the tendon graft cannot come from a separate incision in the same knee. Coders should be aware of where the graft came from.

"[This does] not constitute a far enough distance to bill for it separately, according to CPT guidelines, even though it is not unbundled in the CCI material and it is performed through a separate incision," she says.

3. External fixation. Most fracture treatment codes have been revised so external fixation has to be coded separately, Ms. Jones says. Coders often follow rules from years past, when external fixation was included and inadvertently lose revenue.

4. Sacroiliac joint injections. Sacroiliac joint injections can be confusing because of there are several variations used depending on the procedure and the payor. Coders should use 27096 — which documents the injection procedure for a sacroiliac joint, arthrography and/or anesthetic or steroid — when billing commercial payors or billing the physician's surgical service, Ms. Ellis says.

When billing Medicare for the same procedure, coders should use the CPT G0260, which documents the injection procedure for a sacroiliac joint. Imaging is included in both of these codes and should not be billed separately.    

However, if the joint injection is performed without fluoroscopic guidance or arthrography, coders should use 20610, injection into a major joint. The 20610 code does not include imaging and would be used by both the physician and the ASC facility for billing to all payors, she says.

5. Hardware or implant removals. Deep pin removals done in an ASC require the code 20680. The physician will have to make an incision to visualize the implant, but the code is only to be billed once per fracture or previously operative site, regardless of the amount of hardware removed or the number of incisions made, Ms. Ellis says. The code can only be billed twice if the surgeon removes an implant or hardware from a completely different surgical or anatomical area. 

6. Nerve branch destruction. For pain management treatments, rather than reporting the destruction of each nerve branch separately, coders should be reporting based on each intervertebral joint destroyed, Ms. Jones says. Each joint is supplied by two nerve branches, so coding separately would double the cost of the bill. Physicians may balk if they used a separate needle for each nerve branch, but that does not change the coding. 

CMS To Terminate Common Working File for Eligibility

The Common Working File (CWF) is a single data source for Fiscal Intermediaries and Carriers to verify beneficiary eligibility and conduct prepayment review and approval of claims from a national perspective. It is the only place in the fee for service (FFS) claims processing system where full individual beneficiary information is housed. CWF has four quarterly releases that control, implement, and update software changes due to legislative mandates. Software changes for the claims processing operations are managed in quarterly releases developed through a change control process that begins with the Medicare Change Control Board (MCCB) review and prioritization of pending requests. The FFS Operations Board approves the quarterly releases with oversight by the FFS Governance Council and manages/integrates day-to-day operations of the FFS program across CMS. The FFS claims processing environment is distributed across four (4) claims processing modules and one (1) integrated testing module. This investment directly supports the PMA Improve Financial Performance, as it is an essential component ensuring that accurate payments are made for medically necessary services and are provided to eligible beneficiaries by qualified providers of care. The impact of not funding CWF would be detrimental to Medicare, introducing system errors, causing harmful delays in claims processing and payment, and reducing the access, availability, and provision of health care services to Medicare beneficiaries. Error-free releases that implement legislative mandates with minimal interruption to processing ensure that beneficiaries receive the correct service and providers receive the correct payment. Current Common Working File submitters must seek alternative solution Effective April 1, 2013, the Centers for Medicare and Medicaid Services (CMS) is required to eliminate the Common Working File provider query for eligibility.  What does this mean for you? If you currently use Common Working File queries to verify Medicare eligibility, you must implement an alternative solution by April 1, 2013.