Knowledge Base Category -

The Office of Inspector General (OIG) regularly posts reports of their audit findings. A number of these reports relate to hospital payment errors, although the reports often address the same issues from hospital to hospital. However, I always read through the findings to see if there are any new twists to the issues and to remind myself of these OIG target areas – in other words to see what’s in it for me.

Recently the OIG released three reports of hospital audits – two related to drug payment errors and one general compliance review. Here are a couple of issues from these reports worth noting.

Non-covered Use of Reteplase

The drug reteplase (HCPCS code J2993 – injection, reteplase, 18.1 mg) is approved by the Food and Drug Administration (FDA) to treat cardiac conditions using a single-use dose. The OIG identified a billing error that occurred when a provider billed Medicare for one full single-use dose of reteplase when they had actually split a single dose into multiple doses and used them as a thromblytic agent to clean dialysis patient catheters. This is a non-covered use of reteplase and resulted in an overpayment to the facility. (OIG Report Drug Overpayments Jurisdiction 13)

Bundled IMRT Planning Services

In the OIG Medicare Compliance Review of Good Samaritan Hospital, the OIG identified that the hospital had billed separately for services performed as part of Intensity Modulated Radiation Therapy (IMRT) planning resulting in an overpayment. These services are included in the payment for IMRT planning even when provided on a different date of service.

Hospitals are to report CPT code 77301 for IMRT planning. The Medicare Claims Processing Manual, Chapter 4, section 200.3.2 states that “Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT code 77301.” Therefore these codes should not be billed in addition to IMRT planning (CPT 77301), regardless if provided on the same or different dates of service, unless they are not provided as part of developing the IMRT treatment plan.

A quick review of OIG reports relating to hospital findings is a great way to become familiar with the OIG target areas and to evaluate issues against your hospital’s practices. Better to be proactive than regretfully reactive.

Q:Should physician queries be part of the legal medical record? 

A:

At MMP we have seen facilities maintain queries as part of the legal medical record and other facilities maintain the query forms within the CDI Department. Ultimately, this is a hospital specific decision.

Below are excerpts from two complimentary AHIMA Practice Briefs where they have provided guidance regarding query retention.

Query Retention

Retention of the query varies by healthcare organization. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is kept as part of the business record or only the outcome of the query is maintained in a database.

Before this decision is made a discussion with the facility compliance and legal staff may be beneficial. Regardless, the query should be retained indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate the query wording, even if they are not considered part of the legal medical record.

With the current culture of governmental audits (e.g., RACs and MACs), it is helpful to keep the query a permanent part of the health record to demonstrate compliant and ethical CDI practices. The permanent query demonstrates the CDI professional’s attempt to seek clarification. It also can demonstrate to the administration the CDI professional’s efforts to communicate to the medical staff.

Keeping the query as part of the health record can also refute a healthcare provider’s assertion that he or she was unaware of the need for additional documentation. Finally, a permanent document in the health record serves to reduce redundancy and decrease the risk of a duplicate, retrospective query.

Article Citation: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010); expanded web version.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343

Develop Query Retention Policies

Each organization should develop internal policies regarding query retention. Ideally, a practitioner’s response to a query is documented in the health record, which may include the progress notes or the discharge summary. If the record has been completed, this may be an addendum and should be authenticated. As noted in AHIMA’s toolkit, “Amendments in the Electronic Health Record,” “the addendum should be timely, bear the current date, time, and reason for the additional information being added to the health record, and be electronically signed.”

Organizational policies should specifically address query retention consistent with statutory or regulatory guidelines. The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.

An important consideration in query retention is the ability to collect data for trend analysis, which provides the opportunity for process improvement and identification of educational needs.

Article Citation: AHIMA. “Guidelines for Achieving a Compliant Query Practice.” Journal of AHIMA 84, no.2 (February 2013): 50-53.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018

The term “argue back” is listed as an idiom in an on-line dictionary, similar to the phrases “answer back”, “talk back” or “back talk”. Parents often reprimand their children for “talking back”. However in the grown-up world, making a persuasive argument to support your opinion is not only acceptable, but often necessary to achieve fair and just outcomes. But then again, sometimes life just isn’t fair.

As of this month, the Office of Inspector General (OIG) is approaching 100 reports on Medicare compliance reviews of hospitals. There are similarities between the reports: the issues are often the same, and the reviews are based on computer matching, data mining and data analysis techniques to identify at-risk claims. There are differences between the reports: some hospitals have a much greater overpayment than others and some refund amounts are extrapolated from the overpayment amounts while others are not. We at MMP have not been able to determine a pattern for which audits result in extrapolation versus those that do not.

Last week, the OIG published the report on Compliance Review of University of Cincinnati Medical Center that is particularly interesting. So what makes this report stand out among all the many compliance reviews?

• The refund amount of $9,818,296 was extrapolated from an overpayment amount of $603,267 (to date refund amounts have been extrapolated on only 10 of 99 compliance reviews).
• The refund amount of almost $10 million is the largest of all the compliance reviews. In fact, only three other reviews topped $2M refund and no other refund amounts prior to this one (even other extrapolated reviews) exceeded $5M.
• The University of Cincinnati Medical Center (UCMC) vehemently argued their case at great length against some of the OIG’s decisions from the audit. They make some interesting points in their arguments as noted below.

UCMC believes the OIG claim selection method contains a judgmental bias toward inclusion of claims likely to have overpayments and exclusion of claims likely to have underpayments. The biased findings are further magnified by the use of extrapolation.

UCMC disagreed with 50 of 57 claims the OIG determined were “incorrectly billed as inpatient.” Some of the reasons for disagreement were:

• Some were for inpatient-only procedures
• Reviewers based review decision on information that was not available to the admitting physician at the time of admission
• The hospital was not allowed to have discussion with the reviewers regarding their decisions or request re-review of the cases
• Extrapolation is not appropriate because decisions are judgmental and case-specific, and the potential effect of Part B rebilling is not considered in the extrapolation amount

It is interesting to note that on the seven cases UCMC concurred with, they cite lack of documentation to support the clinical decision of the physician to admit the patient, physician receptiveness to the involvement of RN Case Managers, and interpretation of third party vendor services as weaknesses in existing internal controls.

UCMC was cited for failing to pursue credits for replaced devices. According to UCMC’s response, the Medicare Claim Processing Manual (CMS Pub. 100-04, Sec. 100.8, Replaced Devices Offered Without Cost or With Credit) does not require hospitals to pursue manufacturers for credits on replaced devices. Medicare policy only requires that hospitals report credits actually received where the credit is more than 50% of the cost of the replacement device. UCMC argues that the prudent buyer principle is applicable to defining allowable costs for Medicare cost reports but does not apply to Medicare claims-based audits.

On June 2, 2014, the American Hospital Association (AHA) submitted a letter to the U.S. Department of Health and Human Services also objecting to the OIG hospital compliance audits. The AHA arguments are similar to those made by UCMC and include:

• OIG audits redundant to RAC reviews thereby being unduly burdensome to hospitals
• The OIG misconstrued and misapplied numerous Medicare regulations and policies
• The OIG used flawed sampling and extrapolation methods to estimate overpayments and refunds
• The OIG audits do not take into consideration Part B payments that may have been appropriate for the hospital to receive by their own admission
• They are in violation of reopening time frames and MAC statutory limits on extrapolation

For complete details, read the AHA's letter.

The “arguing back” of both UCMC and the AHA is well thought out, supported by references, and clearly explained, but whether either will prevail concerning their arguments and/or planned appeals remains to be seen.

Q:
We have been told to use modifier 76 on CPT code 93005 when more than 1 EKG is performed on the same date of service, and not to use modifier 59. We are seeing claims where the EKG is hitting our internal billing edit for a CCI conflict. These are scenarios where it would be appropriate to separately report the EKG. Will modifier 76 by-pass a CCI edit? 

A:

No. Chapter 1 of the CCI policy manual states modifier 76 will not bypass a CCI edit.

In your scenario, you would have to use modifier 59 to bypass the CCI edit; this would indicate the EKG was performed as a separate and distinct service from the other procedure(s) hitting the internal CCI edit.

A farmer is selling baskets of apples that were picked several days ago. He knows that some may be bad so he will give a discount based on the percentage of bad apples. The first customer chooses five apples at random and only one of the five is bad, so the farmer gives him a 20% discount. The next customer carefully selects five apples with visible dark spots and all five apples are bad. The farmer gives him a 90% discount. Sometimes it is all in the selection.

In a recent OIG review of payments for selected outpatient drugs, the OIG found that payments for 1,132 of the 1,905 line items for outpatient drugs selected for review were not correct. This appears to be an astonishing error percentage, but beware, this is not a random selection. The OIG uses computer matching, data mining, and other analytical techniques to identify the line items potentially at risk for noncompliance with Medicare billing requirements. Some specific targets mentioned in the report are selected outpatient drugs, payments for drugs that exceeded charges by at least $1,000, and high-dollar payments.

The report found errors involving incorrect units of service, incorrect HCPCS codes, both incorrect units and HCPCS, billing for packaged or non-covered use of a drug, and lack of supporting documentation. Some of the specific drugs and issues include:

• Incorrect units were the cause of most of the billing errors.
• The billable units of a drug can be calculated by dividing the dosage of the drug given by the amount in the HCPCS code description for the drug. For example if 140 mg of a drug is given that has a HCPCS code description of Injection, drug, 1 milligram, then the correct units are 140÷1 = 140 units; if 800 mg of a drug is given that has a HCPCS code description of Injection, drug, 200 mg, then the correct units are 800÷200 = 4 units.
• Leuprolide acetate injections are used for different purposes, each with a different HCPCS code and description.
• HCPCS code J1950, leuprolide acetate injection, 3.75 milligrams per unit, is indicated for the treatment of endometriosis, uterine leiomyoma, and malignant neoplasms of the breast
• HCPCS code J9217, leuprolide acetate injection, 7.5 milligrams per unit is indicated for the treatment of prostate cancer
• Due to difference in Medicare payment rates for these drugs (J1950 - $760.03 and J9217 - $206.78) and the difference in milligram descriptions, billing the wrong HCPCS code for the wrong treatment will result in a significant over or under payment.
• Doxorubicin hydrochloride is available in both a lipid (or liposomal) and a non-lipid (or non-liposomal) formula. The non-lipid form of doxorubicin hydrochloride (HCPCS code J9000) is packaged, whereas the liposomal forms (previously J9001) receive separate Medicare payment. Medicare payment rates for the current HCPCS codes for liposomal doxorubicin (Q2049 and Q2050) are close to $500 per 10 mg.
• Are you using the correct HCPCS code? For example, are your codes correct for:
• Epoetin alfa, 1000 units, for non-ESRD use – J0885
• Darbepoeitn alfa, 1 mcg, non-ESRD use – J0881
• Epoetin alfa, 100 units, for ESRD use – Q4081
• Herceptin – not specifically mentioned in this report because Herceptin audits get their own separate reports. Herceptin is available in a 44mg multi-use vial and Medicare does not pay for drug wastage for multi-use vials. The units of Herceptin billed should be based on the patient’s dosage, not the vials used.

These types of errors may be repeated errors if the reason is a wrong multiplier in the chargemaster. Look for payments that appear too large or too small in relation to the charge amounts.

Hospitals need to make sure the correct drug code is being submitted for the correct treatment purpose.

Your hospital can use the same data mining approach that the OIG uses to check for internal issues with the billing for drugs. MMP’s HIQUP (Hospital Improvement in Quality and Performance) report, which data mines a facility’s Medicare outpatient 835 files, includes several queries designed to identify drugs at high risk of billing errors. So if you are struggling with drug units, please contact us if we can help.

Q:

What discharge disposition do I use if one of our patients is transferred to a swing bed in another hospital since the description for discharge disposition (61) is entitled, “Discharged/Transferred Within This Institution to a Hospital-Based Medicare Approved Swing Bed?”

A:

Discharge disposition (61) may also be used for patients who are transferred to a Medicare-approved swing bed located in another facility. CMS notes that there has been confusion with this discharge disposition and refers us to MedLearn Matters, article SE0408, March 10, 2004 for further review. Please note the two additional references below, Medicare State Operations Manual and the Uniform Billing Editor by Optum also states a patient may be transferred to a Medicare-approved swing bed in another facility.

Medicare State Operations Manual

§482.66 Special Requirements for Hospital Providers of Long-Term Care Services (“Swing-Beds”)

The change in status from acute care to swing-bed status can occur within one facility or the patient can be transferred to another facility for swing-bed admission.

Uniform Billing Editor by Optum

For Medicare, this code is used to report patients who have been discharged/ transferred to a SNF level of care within the hospital’s approved swing-bed arrangement, or to another Medicare-approved swing bed in another location.

Q:

Is it appropriate for a testing laboratory to provide a copy of lab results directly to the patient or their representative?
 

A:

Yes. On February 6, 2014, CMS released a final rule that allows laboratories, upon the patient’s request (or upon the request of the patient’s personal representative), to provide access to completed lab tests results directly to the patient or their personal representative under the Clinical Laboratory Improvement Act (CLIA) and HIPAA privacy regulations. Laboratories that are HIPAA covered entities (i.e. conduct covered health care transactions electronically) are required to provide patients with access to their lab results upon request under this new rule. This final rule is effective April 7, 2014 and HIPAA covered entity laboratories have until October 6, 2014 to comply with the new rule. Prior to this new regulation, CLIA regulations limited the release of laboratory tests results to persons authorized under state law to order and/or receive test results, the person responsible for using the test results in the treatment context, and the laboratory that initially requested the test.

Hospital-based laboratories have a big advantage over independent laboratories in the implementation of this rule. Most hospital laboratories will likely handle the new requirement by directing patients to the Hospital HIM Release of Information (ROI) department. These hospital ROI departments are already knowledgeable concerning the HIPAA regulations and have processes in place to address the requirements of HIPAA, such as positive identification of the person requesting a copy of the medical record, pricing for copies, documentation of the release, etc.

For complete information, please see the CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports; Final Rule.

Were you anxiously awaiting its release? Did you lie awake at night thinking about what old and new features might be included? When it was released, did you drop everything and rush to check it out? No, we are not talking about the latest version of some Smart Phone, a movie sequel, or a new video game. We are talking about the 2014 OIG Work Plan which was finally released at the end of January.

I want to point out a few of the issues, especially billing and payment issues that are most relevant to the types of issues with which we at MMP normally deal. For other issues addressed in the OIG Work Plan that might be of interest to hospitals, see the list at the end of this article.

First, let’s look at some of the issues that are not new to this year’s work plan.

• Compliance reviews of acute care hospitals to determine compliance with selected inpatient and outpatient billing requirements. These types of reviews have been ongoing for several years and address a number of different billing issues, including but not limited to medical necessity of inpatient admissions, inpatient DRG coding, outpatient CPT/HCPCS codes, discharge status, device credits, and units of service.
• One of the most notable aspects of these reviews is that in four of the 87 compliance reviews to date, the OIG has extrapolated the overpayment amount causing an overpayment of hundreds of thousands of dollars to become millions of dollars.
• Inpatient claims for mechanical ventilation to determine if the hospitals’ DRG assignments and payments are appropriate. For certain DRGs to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation. Past OIG reviews have revealed overpayments when one of these DRGs was assigned, but the patient did not receive 96 or more hours of mechanical ventilation.
• Outpatient dental claims have also been previously identified at risk for overpayments. Generally dental services are excluded from Medicare coverage with only a few exceptions. Examples of covered dental services would be if teeth have to be removed in order to perform another covered procedure, such as excision of a tumor or to prepare for radiation treatments.

New OIG activities for 2014 include:

• Determining the impact of new inpatient admission criteria on hospital billing, Medicare payments, and beneficiary payments. The new admission criteria of a two-midnight expectation are substantially different than the previous admission criteria. Previous OIG reviews found overpayments, inconsistencies, and inappropriate billing under the old rules. It will be interesting to see if the new rules result in improved consistency or not.
• Review of Medicare outpatient payments to hospitals for clinic visits billed at the new patient rate. Prior to this year clinic visits were billed with Evaluation and Management (E&M) codes including both new and established patient codes. The higher paying “new patient” codes were only to be used if the patient had been registered as an inpatient or outpatient at the hospital within the past three years. With the changes to clinic visit reporting for 2014, hospitals no longer have to differentiate new vs. established patients or different levels of service intensity for clinic visits.
• Review of cardiac catheterizations and heart biopsies. Right heart catheterizations performed during the same operative session are included in the heart biopsy procedure and should not be billed separately unless a separate medical necessity for the right heart catheterization can be established eg: evaluate for rejection; failed previous heart procedure; compromised pulmonary status, etc.
• The OIG will review Medicare payments made to hospitals for claims that include a diagnosis of Kwashiorkor to determine whether the diagnosis is adequately supported by documentation in the medical record. Kwashiorkor is a severe form of protein malnutrition that is usually not found in the United States. Coding malnutrition as Kwashiorkor results in a larger payment from Medicare that is not appropriate if the patient really does not have this type of malnutrition.
• Although this is listed as a new issue, the OIG has already released three audit reports addressing this topic from January and February 2014. The reports note that Medicare paid hospitals $711 million for claims that include a diagnosis of Kwashiorkor. The audits have found no claims where the diagnosis of Kwashiorkor was appropriate. Removing the Kwashiorkor diagnosis has changed the DRG in about 18% of the claims reviewed, resulting in total overpayments for the three reviews exceeding $310,000.

Other Topics in the Work Plan include:

Hospitals; Policies and Practices:

Reconciliation of outlier payments
Medicare costs associated with defective medical devices (new)
Analysis of salaries included in hospital cost reports (new)
Impact of provider-based status on Medicare billing
Comparison of provider-based and free-standing clinics (new)
Critical Access Hospitals - Payment policy for swing-bed services
Critical Access Hospitals - Beneficiary costs for outpatient services
Long Term Care Hospitals - Billing patterns associated with interrupted stays

Hospitals: Billing and Payments:

Duplicate graduate medical education payments
Bone marrow or stem cell transplants (new)
Indirect medical education payments (new)

Hospitals: Quality of Care and Safety:

Participation in projects with quality improvement organizations
Emergency preparedness and response - Hurricane Sandy (new)
Oversight of pharmaceutical compounding (new)
Oversight of hospital privileging (new)
Adverse events in inpatient rehabilitation facilities

Nursing Homes:

Questionable billing patterns for Part B services during nursing home stays

Other Providers: Billing and Payments

Diagnostic radiology – medical necessity of high-cost tests
Electrodiagnostic testing – questionable billing
Laboratory tests – billing characteristics and questionable billing
Partial hospitalization programs
High utilization of sleep-testing procedures

Q:

When we perform a self-audit after a patient has been discharged and the documentation does not support a 2-Midnight expectation do we have to notify the beneficiary of the change from a Part A claim to a Part B claim?

A:

This question was addressed on pages 50913 – 50914 of the 2014 IPPS Final Rule.

Commenters asked that CMS clarify whether or not they were “proposing a self-audit process that would have to conform to the utilization review rules under the CoPs, notably physician concurrence, beneficiary notification, and other aspects related to continuation of an inpatient stay.”

CMS’s response was that “we did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self audit determination that does not conform to the requirements for utilization review under the CoPs. We do not agree with the commenters that beneficiaries need not be notified of a hospital’s determination that the inpatient admission was not reasonable and necessary. Part B billing pursuant to such a determination may result in an increase in financial liability for some beneficiaries which hospitals may not be able to ‘‘waive’’ or forego attempting to collect (we refer readers to sections XI.B.5 and B.6. of the preamble of this final rule). We believe that the CoP rules for beneficiary notification and physician involvement in hospital utilization review decisions are important for maintaining beneficiary rights, consistent with 42 CFR 482.13.”

§482.30 Condition of participation: Utilization Review

This CoP instructs that if after review the Utilization Review Committee determines that a stay was not medically necessary, written notification must be provided to the hospital, patient and MD responsible for the patient’s care, within 2 days of the decision being made.

Question:

Were there any changes to the Post-Acute Transfer and Special Payment Policy in the 2014 IPPS Final Rule?

Answer:

MLN Matters® Number: MM8421 (Effective Date: October 1, 2013) indicates that no changes were made to the Post-acute and Special Post-acute payment policy or applicable DRGs for FY 2014.

This article goes on to “note that the new Patient Status codes (81-95) that refer to ‘Planned Readmissions’ have been mapped to their non-planned readmission counterparts and are included in the transfer policy.

The entire MLN Matters® article can be found at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8421.pdf