Reed Tinsley, CPA

Coding Trends of Medicare Evaluation and Management Services

In May 2012, the Department of Health and Human Services Office of Inspector General (OIG) issued a report entitled “Coding Trends of Medicare Evaluation and Management Services.” This study was conducted because between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent, from $77 billion to $110 billion. During this same time, Medicare payments for evaluation and management (E/M) services increased by 48 percent, from $22.7 billion to $33.5 billion.

What did the Study find? From 2001 to 2010, physicians increased their billing of higher level E/M codes in all types of E/M services. Among these physicians, the OIG identified approximately 1,700 who consistently billed higher level E/M codes in 2010. Although these physicians differed from others in their billing of E/M codes, they practiced in nearly all States and represented similar specialties. The physicians who consistently billed higher level E/M codes also treated beneficiaries of similar ages and with similar diagnoses as those treated by other physicians.

CMS will conduct additional reviews of physicians who consistently bill higher level E/M codes to ensure that their claims are appropriate. If CMS determines that inappropriate claims have been paid, it will take steps to recover those overpayments. So my advice is to look closely at your physician practice's E/M patterns; if you think there might be an overcoding issue, have a sample of charts reviewed by an independent coding consultant to ensure the medical record documentation supports the level of E/M service billed.

Medicare moves to tie doctors’ pay to quality and cost of care

Interesting article in the Washington Post - can Medicare really move this way? I doubt it - very hard to make an elephant dance.

http://www.washingtonpost.com/national/health-science/medicare-moves-to-tie-doctors-pay-to-quality-and-cost-of-care/2012/04/14/gIQAFq3IIT_story.html?wpisrc=nl_headlines

Medicare moves to tie doctors’ pay to quality and cost of care

Interesting article in the Washington Post - can Medicare really move this way? I doubt it - very hard to make an elephant dance.

http://www.washingtonpost.com/national/health-science/medicare-moves-to-tie-doctors-pay-to-quality-and-cost-of-care/2012/04/14/gIQAFq3IIT_story.html?wpisrc=nl_headlines

Medicare says a physician MAY bill incident to another physician’s services

This is big news! My friend and colleague David Zetter (www.zetter.com) has been in discussions with CMS in Baltimore about this issue. He recently posted the following email to the NSCHBC listserv (www.nschbc.org):

Hello Everyone-

I thought I would share some information with you that I found out today from CMS in Baltimore via a phone conversation and documented in an email. I know that this will take some of you by surprise, because it did me.

A physician MAY bill incident to another physician’s services as long as they meet the “incident to” regulations found in 42 CFR Ch IV § 410.26. This comes straight from the person’s mouth that wrote the regulations at CMS.

What makes this significant is that a new physician to a practice may see patients and bill incident to another physician’s services prior to their effective date of enrollment or reassignment with Medicare. The new physician would bill via the supervising physician’s NPI as the rendering provider. The new physician wouldn’t be identified on the claim for services at all, BUT the supervising physician WOULD be held liable for all services and SHOULD sign off on all service notes and reports for the patients seen. This would be our recommendation to our clients.

Mr. Zetter,

I wanted to respond to your questions directly. I work in the Division of Practitioner Services on incident to payment policy.

I understand your concerns. There are situations where a physician billing for another physician could be used to hide unethical practices. While it is true that we do not specifically name physicians as auxiliary personnel for the purposes of incident to, we also do not name any type of medical professional as auxiliary personnel in the definition. We also do not require that the auxiliary personnel be a lower level professional. The definition is broad enough to include physicians and many other types of health care providers and staff. We also stated in the preamble text of the CY 2002 Physician Fee Schedule final rule with comment period that, “We deliberately used the term any individual so that the physician (or other practitioner), under his or her discretion and license, may use the service of anyone ranging from another physician to a medical assistant.” While I do not think it is the typical case for incident to, it is not prohibited for a physician to directly supervise another physician and bill under the incident to provision when all the required conditions are met.

Please contact me if you have any follow up questions or concerns.

Best regards,
Erin
Centers for Medicare and Medicaid Services

Best regards,

DJZ

CMS has published a revised Medicare Physician's Guide

This publication has been developed for Medicare Fee-For-Service (FFS) providers and suppliers. It provides the following information about the Medicare Program:

• Introduction to the Medicare Program;
• Becoming a Medicare provider or supplier;
• Medicare reimbursement;
• Medicare services;
• Protecting the Medicare Trust Fund;
• Medicare overpayments and FFS appeals; and
• Provider outreach and education.

http://www.cms.gov/MLNProducts/downloads/MedicarePhysicianGuide_ICN005933.pdf

OIG Alerts Physicians to Exercise Caution When Reassigning Their Medicare Payments

Physicians who reassign their right to bill the Medicare program and receive Medicare payments by executing the CMS-855R application may be liable for false claims submitted by entities to which they reassigned their Medicare benefits.

The Office of Inspector General (OIG) encourages physicians to use heightened scrutiny of entities prior to reassigning their Medicare payments. Physicians should carefully consider entities to which they choose to reassign their Medicare payments and ensure that the entities are legitimate providers or suppliers of health care items and services.

The OIG recently reached settlements with eight physicians who violated the Civil Monetary Penalties Law by causing the submission of false claims to Medicare from physical medicine companies. Specifically, these physicians reassigned their Medicare payments to various physical medicine companies in exchange for Medical Directorship positions. While serving as Medical Directors, the physicians did not personally render or directly supervise any services. There was evidence that the services the physical medicine companies claimed the physicians performed were not actually performed or were not performed as billed.

The failure of the physicians to monitor the services billed using their reassigned provider numbers resulted in individuals with little to no medical background serving as physical therapy "technicians." These unlicensed "technicians," including retail cashiers and massage therapists, rendered unsupervised in-home physical therapy services to Medicare and Medicaid beneficiaries. The physical medicine companies falsely billed Medicare using the physicians' reassigned provider numbers as if the physicians personally rendered the services or directly supervised a "technician" rendering the services. Many of the owners and operators of the physical medicine companies were criminally prosecuted. OIG determined that the physicians were an integral part of the scheme and pursued their liability under the Civil Monetary Penalties Law.

Note: A physician who reassigns to any entity his or her right to bill the Medicare program and receive Medicare payments has the right to access the entity's billing information concerning the services the physician is alleged to have performed and for which the entity billed Medicare. Physicians have unrestricted access to claims submitted by an entity for services that the entity billed using the physicians' reassigned provider numbers to provide added assurances that the services for which the entity billed Medicare were, in fact, performed and were performed as billed.

 

Items and Services That Are Not Covered Under the Medicare Program

This publication published by the Medicare Learning Network provides the following information:

• The four categories of items and services that are not covered under the Medicare Program andapplicable exceptions to exclusions;

• The Advance Beneficiary Notice of Noncoverage (ABN); and

• Resources.

This is an excellent learning tool for your billing staff, so I suggest you make a copy for each person.

https://www.cms.gov/MLNProducts/downloads/Items_and_Services_Not_Covered_Under_Medicare_BookletICN906765.pdf

RACs Recover $797 Million In Overpayments

Medicare Recovery Audit Contractors (RACs) collected $797.4 million in overpayments during Fiscal Year (FY) 2011, the Centers for Medicare and Medicaid Services (CMS) reported recently.

Under the national program, RACs in four regions of the country, as designated by CMS, are paid a contingency fee for identifying overpayments/underpayments in Medicare Parts A and B. They must return any fees for payments that are later determined not to be improper.

NOTE: I have solo medical practice clients who have gone through RAC audits, so nobody is immune from scrutiny. So make sure your billing house is in order!

OUCH-Possible big cut in physician Medicare reimbursements?

Centers for Medicare & Medicaid Services (CMS) has released its Calendar Year (CY) 2012 Final Rule with Comment Period for practitioners who are paid under the Physician Fee Schedule (PFS). The final rule impacts a variety of methodologies used to calculate physician payment, including the adjustment for geographic differences in practice expenses and the payment rates for the professional component of multiple advanced diagnostic imaging procedures.

CMS anticipates that, without changes to current law, the Sustainable Growth Rate (SGR) adjustment to physician reimbursement will result in a 27.4% cut in payment rates for 2012. This adjustment has historically been reversed through congressional intervention. However, in light of the ongoing impasse over budget cuts required by this summer's debt ceiling debate, the possibility looms that no legislative fix will be forthcoming. As a result, there is a very real possibility that a substantial reduction in physician reimbursement will occur with the CY 2012 PFS.

RAC update

CMS has released a report entitled “Implementation of Recovery Auditing at the Centers for Medicare & Medicaid Services.” The report discusses the evolution of the Recovery Audit Contractor (RAC) program, describes key program components, and provides detailed FY 2010 results, including collection and underpayment data by claim type and issue.