• CMS Issues Medicare Provider Compliance Newsletter with Guidance to Avoid Common Problems Identified by Recovery Auditors
  • March 10, 2011
  • Law Firm: King Spalding LLP - Atlanta Office
  • CMS has issued its second Medicare Quarterly Provider Compliance Newsletter.  Inside, CMS identified seven errors often found by Recovery Auditors and provided guidance to avoid those errors in the future.  Of the seven common errors, two affect inpatient hospitals, two affect physicians, one affects both outpatient providers and physicians, and two affect durable medical equipment (DME) suppliers.

    Both inpatient hospital errors involve incorrect coding.  First, Recovery Auditors often found non-excisional debridement incorrectly coded as excisional debridement.  The code for excisional debridement applies only to the “surgical removal or cutting away of devitalized tissue, necrosis, or slough.”  Non-excisional debridement is applicable for debridement using autolytic, enzymatic, or mechanical methods.  Second, Recovery Auditors frequently found that inpatient hospitals inappropriately billed for the creation of a new tracheostomy when the patient merely underwent a revision to an existing tracheostomy, which has a unique code.

    The two errors affecting physicians related to billing for evaluation and management (E/M) services.  First, Recovery Auditors often found that providers billed E/M services the day before and up to 90 days after surgeries.  The Global Surgical Package includes E/M services within a specific window surrounding surgery; thus, physicians may not bill separately for E/M services within that window.  Second, Recovery Auditors frequently found that physicians billed “new patient” E/M services for existing patients.  Medicare defines “new patient” as a patient who has not received any professional services, e.g. E/M, from the physician within the previous three years.  Thus, Medicare may be billed only once for “new patient” E/M for the same beneficiary within any three-year period.

    Recovery Auditors also noted that providers billed more than one initial infusion code per day.  This problem affects both outpatient providers and physicians.  Medicare will reimburse only one initial infusion code per day, unless two separate intravenous sites are necessary.  If two sites are required, providers must append a modifier; otherwise, payment may not be made.

    Finally, Recovery Auditors identified two problems affecting DME suppliers.  First, suppliers often incorrectly billed for items and services relating to a hospice terminal diagnosis.  Medicare will not reimburse these items and services because they are included in the hospice payment, and suppliers should bill the hospice.  Second, suppliers often billed for quantities of budesonide greater than 62 units of service per month, which is the maximum amount reimbursed.

    For each of the seven errors, CMS cited relevant manual provisions for quick reference.  In general, providers can avoid these errors by following the guidance found in those provisions.