9/17/2018. Non-covered services. Description: Billing for services not covered under the Medicare program

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1 Top billing and coding errors: Duplicate claims submitted The claim was previously processed (no payment made, allowed amount applied to deductible on the initial claim). The provider re-files the claim to correct it. The second claim submitted is considered a duplicate, as the initial claim was processed correctly. The provider automatically re-files the claim to seek payment if the initial claim has not been paid within 30 days. Non-covered services. Description: Billing for services not covered under the Medicare program Stay up-to-date on current exclusion policies by checking with your Medicare carrier and their web site for changes. Most carriers will post changes to policies and their effective date. If not, go directly to Medicare s web site at and find them there. 1

2 Lack of medical necessity. Description: The payer deems the service billed not medically necessary. The claim will be denied because the payer does not deem the procedure for this diagnosis to be a medical necessity. Inappropriate bundling of services. Description: This indicates a lack of awareness of the National Correct Coding Initiative (NCCI) that govern appropriateness of tests being performed together on the same date of service. Alternately, it may indicate a lack of understanding of the appropriate code status of a specific CPT code. Access the NCCI Edits on the Medicare web site to review which codes can and cannot be billed together on the same date of service, as well as the appropriate modifiers to use in those situations. Beneficiary eligibility. Description: You submit a claim for processing and the beneficiary/patient does not have Medicare eligibility. Claims are often denied for eligibility for the following reasons: The beneficiary Medicare number is invalid on the claim. The beneficiary is not eligible to receive Medicare benefits. The beneficiary s claims must be filed to another insurance plan. 2

3 Incorrect carrier. Description: The claim was submitted to the incorrect payer/contractor for payment. It s important to screen patients and be aware of the types of services provided prior to submitting a claim to the carrier. Check the patient s Medicare card and verify the health insurance claim (HIC) number on the card. Medicare is the second payer. Description: The care of a Medicare patient may be covered by another payer through coordination of benefits. Medicare may be the secondary payer in our offices for the following reasons: The rule: Working ages. The Medicare patient is:65 years or older, employees full or part time by an employer who has 20 or more full or part time employees, and covered under the employer s group health plan (EGHP): or covered under the EGHP of an actively employed, full or part time spouse whose employer has 20 or more employees. Liability and auto/no fault liability: Section 953 of the Omnibus Budget Reconciliation Act of 1980 was amended by the Deficit Reduction Act of It precludes Medicare payment for items or services to the extent that payment has been made or can reasonably be expected. Where the primary claim should be filed under auto, medical, personal injury protection PIP), no-fault, worker's compensation, or any liability insurance plan or policy including self-insurance plans. Worker s compensation: Medicare will be the second payer for work-related illnesses or injuries covered under a worker s compensation plan. 3

4 Veterans Affairs (VA): VA records are set-up by information received by the Social Security Administration. Veterans who are entitled to Medicare may choose which program will be responsible for payment of services covered by both programs. Incorrect Diagnosis. Description: Services were denied because the diagnosis listed as primary was not a covered diagnosis for the procedures performed. Keep in mind that having a covered diagnosis does not mean you can automatically perform any procedure for which the covered diagnosis exists. You must prove and document the reason in the medical record to justify doing the procedure. The claim is missing a modifier or has an incomplete or invalid modifier. Description: The modifier necessary to process the claim correctly is either missing, incomplete, or invalid for the specific procedure and diagnosis indicated on the claim form. Know the proper use of the CPT modifiers that exist and are appropriate to use for the specific condition or situation. The CPT modifiers are listed in their entirety in Appendix A of the current version of the CPT manual. 4

5 Duplicate billing: filling claims more than once for the same service Stark Violations: Physicians referring patient to services in which they have a financial interest. Pharmaceutical Coding in Physicians Offices: Incorrect use of codes or units in billing of injections. Social Work Services in Facilities: Some clinical social worker services provided to inpatients in hospitals or skilled nursing facilities cannot be billed under part B. Psychiatric Services: Over utilization of psychiatric services provided in the outpatient setting. Medical Necessity: Documentation not supporting the level of service provided in the outpatient setting. E/M Billed During Global Periods: Use of modifier 24 in billing services that should have been included in the global package. Place of Service Errors: Physicians performing services in ASCs or outpatient facilities but when billing applying a place of service code indicating the service was performed in the physician office. 5

6 Incident to Errors: Physician assistants and nurse practitioners performing services for a physician but not following billing-specific guidelines related to the physician s relationship to the patient and the physician s presence in the office. Debridement Coding: Errors in coding surgical debridement versus active wound care management. Upcoding Documentation in the chart does not support the level of service. Downcoding: Documentation in the chart supports a higher level of service. Chief compliant or reason for the visit missing from the note. Assessment is not always clearly documented. Provider cannot use rule out, probable, or suspected conditions for a diagnosis; however, providers should document suspected conditions to get credit for the medical necessity for the service along with documenting sign and/or symptoms. Documentation is not initialed or signed. Tests ordered are not always listed in the documentation, but billed on the encounter form/superbill. When tests are ordered, documentation in the plan of care. Documentation of medication is not always clear. Diagnosis not always referenced correctly. Documentation missing. Lost dictation. 6

7 Superbill/encounter form and/or charge (fee) ticket not available. Superbill/encounter is incomplete or incorrect. Documentation is illegible. An Office of Inspector General (OIG) audit of the Health Care Financing Administration (HCFA) revealed errors in 30 percent of all claims paid by HCFA. These errors account for approximately $23.2 billion annually, or 14 percent of total Medicare fee-forservice (i.e., excluding managed care) payments. About half of the errors identified resulted from insufficient or lack of documentation from providers, and one-third of the documentation errors were associated with providers who failed to respond to repeated requests from auditors to submit documentation. Source: As a result of these audit findings, providers can expect to see increased efforts by the federal government to prevent, identify, and punish healthcare fraud. HCFA's action plan to address the problems identified by the OIG audit includes the following measures: Increased number of prepayment reviews Increased postpayment reviews of medical necessity and medical record documentation supporting claims Source: 7

8 Overpayment recovery Providers identified by the audit as submitting improper claims will be targeted for more extensive investigation Increased review of evaluation and management claims (as of October 1998, HCFA plans to increase the number of random prepayment reviews of evaluation and management claims) Demand for more documentation from providers who submit claims Increased security measures to prevent submission of claims from improper providers Source: What does this mean for you the coder? What can you do to reduce the chance of your employer becoming a target of a fraud investigation related to coding? How can you assure and demonstrate that your organization has accurate, ethical coding practices and medical record documentation that supports the diagnoses and services reported on the claim for reimbursement? 8