Medicare clarifies, updates several claims payment issues

The Centers for Medicare and Medicaid Services has released statements regarding claims payment issues that it will be correcting in the near future, including enforcing coding conventions and restructuring system edits.

The Centers for Medicare and Medicaid Services (CMS) has released statements regarding claims payment issues that it will be correcting in the near future. Some of the corrections involve enforcement of coding conventions; others involve restructuring system edits. ACP strongly encourages its members to be sure their Medicare Part B claims are in accord with the rules, to avoid claim denials.

No more ICD-10 delays

Despite persistent rumors that the ICD-10 code set will be delayed again, pushing it beyond the Oct. 1, 2014 date, CMS emphasizes that it is committed to switching over on schedule.

The very last additions to the ICD-9-CM codes will be introduced in the calendar year 2014 Inpatient Prospective Payment System (IPPS) proposed rule, which is scheduled for publication in April 2013. The IPPS final rule will follow in August 2013. After that, no more ICD-9 codes will be created during the partial freeze of the code set.

CMS has updated its projected timelines for ICD-10 implementation, which are online. According to its timeline, practices and facilities should be in or near their initial testing phase for claims and related transactions. Your system updates should be done by this summer. Industry-wide testing needs to happen this year.

CMS emphasizes that it is committed to working with small practices and their vendors on the transition process.

Duplicate AWV payments

For dates of service on and after Jan. 1, 2011, that Medicare processed on and after April 4, 2011, through March 31, 2013, the Medicare systems mistakenly allowed an Annual Wellness Visit (AWV) (Healthcare Common Procedure Coding System [HCPCS] codes G0438 or G0439) to be billed on an institutional claim and a professional claim for the same patient on the same day. In some cases, this resulted in double billing of the same service, since institutional and professional claims may be submitted for the same types of services. In other instances, both professional and institutional claims have been received for the same patient with different dates of service.

Medicare contractors are updating their systems to prevent future overpayments by allowing payment only for either the practitioner or the facility for furnishing the AWV. Recoveries began on April 1, 2013.

Going forward, CMS will accept claims for payment from facilities furnishing the AWV in a facility setting only if no physician claim for professional services has been submitted to CMS for payment. When duplicate AWV payments are recovered from physicians, the beneficiaries will be notified that they are not responsible for reimbursing the clinicians for the recovered amount.

Reminder: The initial AWV (G0438) is a once-in-a-lifetime benefit for Medicare beneficiaries. The subsequent AWV (G0439) can be provided to a beneficiary if the beneficiary has not received an Initial Preventive Physical Examination (IPPE) or an initial AWV (G0438) within the previous 12 months.

Repayment of RAC audit costs

In a quiet announcement that nearly went unnoticed, CMS began a policy of reimbursing some of the costs of copying and mailing medical records related to a Recovery Audit Contractor (RAC) request. Effective April 1, 2012, CMS began instituting a reimbursement cap of $25 per medical record. Any medical record submitted to a recovery auditor after April 1, 2012, can receive a maximum of $25 per medical record. This includes both the $0.12 per-page cost for photocopying, as well as first-class postage. For more information, please go online.

Billing E/M with surgeries

When Medicare Part B evaluation and management (E/M) visits are billed for the same date as global period surgeries (0-day, 10-day, and 90-day), the E/M service is automatically bundled into the surgical fee, not paid separately. This applies not only to major surgery but also to minor surgeries (even those with 0-day global periods). Examples of minor surgeries are:

  • 60100: biopsy thyroid, percutaneous core needle (0-day global period) and
  • 11200: removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (10-day global period).

This coding rule, which has been in place since 2006, is now the focus of more claims contractors' attention and potentially the subject of audit issues. More information is available from CMS in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, online.

Changes to medically unlikely edits

The medically unlikely edits (MUEs) used by CMS and some other payers will change this spring to prevent overpayments for services billed on a single date of service. A Government Accountability Office (GAO) review of Medicare-paid claims found that many were overpaid because of the way they were coded.

An MUE is a “same provider, same patient, same date of service” edit. The MUE value is the maximum units of service that most physicians and providers would report for a Current Procedural Terminology (CPT) or HCPCS code for the vast majority of patients receiving the service. Although the MUEs were designed to detect services billed for the same date, the claims processing did not reliably catch multiples of units when they were billed on different lines of the claim. Due to the processing errors and a recommendation from the GAO to convert the MUEs to date-of-service edits, physicians and other providers can expect to see payment denials if their claims are not correctly coded.

Most physicians are instructed to report multiple units of the same service/CPT/HCPCS code on a single line, reporting the total number of units for that particular service. For surgery claims involving bilateral anatomic structures, be sure to properly use CPT modifier 50. However, this guidance does not apply to physicians who provide services in ambulatory surgical centers (ASCs). ASC facility providers generally report a bilateral surgical procedure on two separate claim lines using modifiers RT (right) and LT (left) and report one unit of service on each line.