Posts tagged Coding
After years of Litigation, E/M Denials Persist
Aug 20th
Notwithstanding years of litigation and multi-million dollar settlements, many healthcare providers continue to experience inappropriate evaluation and management service (“E/M”) denials. Earlier today, I spoke with a provider who had a well-founded complaint regarding his denials, so I want to take a minute to quickly review the basics.
E/M is a visit or consultation provided by a healthcare provider. Each E/M can be identified by a unique Current Procedural Terminology (“CPT”) code such as 99203, which identifies an outpatient visit with a new patient presenting with symptoms that are of moderate severity.
As a general rule, payers will not provide separate reimbursement for E/M services that are directly related to and necessary for your performance of the procedure on the same day as the E/M for which you are obtaining reimbursement. Nevertheless, as described below by Medicare, E/M is reimbursable in certain scenarios if modifier 25 is properly utilized. Specifically, Medicare explains:
Modifier 25 is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable evaluation and management service performed by the same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.
When you use modifier 25, you should make certain that your records support the separate and distinct nature of the services. Naturally, your records should clearly document history, examination and decision-making.
While your medical notes need not be submitted with the claim (unless you are in a pre-payment audit), they will be needed in the event of a post-payment audit of your use of modifier 25. If you are audited, comprehensive medical notes will likely ensure that you can retain your reimbursements and will prevent the payer from broadening the scope of its audit.
Disclaimer: The information contained within the MTBC® Learning Center is provided for general educational and informational purposes only and should not be construed as legal advice. The author of the Learning Center does not represent the Web site user or the individual submitting a particular question. Please seek the advice of legal counsel to address any specific questions you may have regarding your particular facts or circumstances
CMS Proposes Doubling the Number of Non-reimbursable Hospital-Acquired Conditions
Apr 17th
My August 13, 2007 blog discussed CMS’ then-groundbreaking move to deny reimbursement for seven hospital-acquired conditions including pressure ulcers, hospital falls, certain catheter-associated infections, air embolism as a result of surgery, leaving an object in during surgery, providing incompatible blood or blood products and mediastinitis following coronary bypass surgery. CMS has now announced that it proposes expanding the list to include the following nine conditions:
- Surgical site infections following certain elective procedures
- Legionnaires’ disease
- Extreme blood sugar derangement
- Lung collapse (Iatrogenic pneumothorax)
- Delirium
- Ventilator-associated pneumonia
- Formation/movement of a blood clot (Deep vein thrombosis/Pulmonary Embolism)
- Bloodstream infection (Staphylococcus aureus septicemia )
- Bacterial infection that causes severe diarrhea and serious intestinal conditions such as colitis (Clostridium difficile associated disease)
CMS has explained that the underlying rationale for denying reimbursement is “to strengthen the tie between the quality of care provided to Medicare beneficiaries and payment for the services provided when they are in the hospital.” This goal is consistent with – and, in fact, mandated by – the Deficit Reduction Act of 2005 (Pub. L. 109-171), which requires the Secretary to identify certain high cost and/or high volume preventable conditions that result from inadequate hospital care and are identifiable by unique ICD-9-CM codes.
There are two final things you should know about CMS’ latest move. First, these new reimbursement rules will not have a direct or immediate impact on individual physicians. Second, if you manage hospital A/R, you are prohibited from billing patients for these claims, even though they will be denied by Medicare.
Disclaimer: The information contained within the MTBC® Learning Center is provided for general educational and informational purposes only and should not be construed as legal advice. The author of the Learning Center does not represent the Web site user or the individual submitting a particular question. Please seek the advice of legal counsel to address any specific questions you may have regarding your particular facts or circumstances
Medicare will Deny Claims Relating to Hospital-Acquired Conditions
Aug 13th
Newly adopted Medicare regulations make it clear that Medicare intends to stop reimbursing hospitals for expenses associated with “hospital-acquired conditions”.
Background
Pursuant to the Deficit Reduction Act of 2005 (Pub. L. 109-171), the Secretary identified certain high cost and/or volume preventable conditions that result from inadequate hospital care and are identifiable by unique ICD-9-CM codes. In accordance with the Congressional mandate, CMS will no longer provide reimbursement for such specified hospital-acquired conditions. See 42 C.F.R. 411, et seq..
Non-reimbursable Claims
While many conditions were considered, the list was eventually narrowed down to the following conditions for which Medicare will not provide any reimbursement:
- Pressure ulcers
- Hospital falls
- Certain catheter-associated infections
- Air embolism as a result of surgery
- Leaving an object in during surgery
- Providing incompatible blood or blood products
- Mediastinitis following coronary bypass surgery
It should be noted that existing Medicare regulations prohibit the balance billing of patients. Therefore, if Medicare denies payment for these hospital-acquired conditions, a hospital cannot attempt to pass these costs onto its patients.
Implications for Providers
By some estimates, numerous hospitals will experience millions of dollars in annual reimbursement denials as a result of the new Medicare regulations. However, these new reimbursement rules will not have a direct or immediate impact on physicians. Nevertheless, they do indicate a new direction for Medicare and it is likely that Medicare will eventually apply similar rules to health care providers.
Disclaimer: The information contained within the MTBC® Learning Center is provided for general educational and informational purposes only and should not be construed as legal advice. The author of the Learning Center does not represent the Web site user or the individual submitting a particular question. Please seek the advice of legal counsel to address any specific questions you may have regarding your particular facts or circumstances