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Common missteps can result in compliance reimbursement violations
Part 2 of a three-part series looking at problems that can result from ASC coding errors.
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A note from the editors:
 Riva Lee Asbell |
In the Jan. 15 issue of Ocular Surgery News (page 10) coding consultant Riva Lee Asbell discussed how ASC coding errors can lead to lost revenue or a breach in compliance regulations. In this second part of a three-part series, she continues the conversation with a look at common mistakes that can result in compliance reimbursement violations.
In January 2008, we are scheduled to begin the first stage of Medicare’s ASC Payment Reform, which certainly will herald a new era in ASC payment. However, unlikely as it may seem, the compliance issues probably will be similar to the ones we now encounter. Let’s take a look at some common issues. Here are five mistakes resulting in compliance reimbursement violations.
Mistake 1. Performing procedures not on the list
Under the proposed rule for the new Medicare payment system, the list of procedures will be an exclusionary one rather than the present inclusionary one. For 2007, however, the list remains inclusionary, and the procedures must be on the ASC list in order to bill Medicare for them. If not on the list, they must be dealt with in a special way.
If a performed surgery is a covered procedure by Medicare but is not on the list, the facility is prohibited from billing the patient for the facility fee. Nevertheless, a facility fee must be billed lest the ASC be regarded as providing an inducement to the physician for performing his cases in that specific facility. The ASC thus needs to bill the physician for a facility fee.
As Eric Zimmerman, JD, MBA, has noted, “Not only are ASCs generally limited by Medicare to furnishing surgical procedures, but the federal anti-kickback statute also may be implicated where the physician is permitted to bill both the professional and technical component of a service, and the ASC does not attempt to collect fair market value for use of its facility from the physician. If the ASC does not receive fair market compensation for permitting the physician to furnish a service there, it might appear as though the ASC is providing the physician with something of value to induce referrals.
“ASCs generally should require physicians to reimburse the facility for staff and supply costs, as well as operating room time associated with services for which the facility cannot seek reimbursement from Medicare or the patient.”
Common procedures that I have seen performed on Medicare patients that fall into this category include examinations under general anesthesia, laser procedures, excision of lesions and intravitreal injections.
Mistake 2. CPT coding errors and compliance violations
A surfeit of errors falls into this category and includes the following violations:
Using the wrong code. CPT code selection must be provided by the physician, and it must be done at the end of the operation. Billers or coders usually are not sufficiently grounded in the clinical aspects of surgery to perform code selection in cases other than routine ones such as cataract extraction with insertion of an IOL.
Deliberate selection of the wrong code. This is usually done to enhance reimbursement and is fraudulent in nature.
Deliberate upgrade of the code selection. This is self-explanatory and includes coding procedures on the list when, in fact, a procedure not on the list was performed. Here are some examples revealed in recent audits.
- Selecting orbitotomy with bone flap or window when performing the same procedure without bone flap (using CPT code 67420 rather than 67412).
- Selecting the functional upper eyelid blepharoplasty code rather than the cosmetic upper eyelid blepharoplasty code (using CPT code 15823 rather than 15822).
- Selecting excision of lesion with rotation flap rather than simple excision of lesion (using CPT code 14060 rather than 67840, which is not on the list of approved procedures).
- Selecting CPT code 66172 (trabeculectomy in presence of scarring) rather than 66170 when no prior incisional surgery was performed.
Deliberate participation in miscoding adventures. A major example is using code 65772 (corneal relaxing incision for surgically induced astigmatism) for cosmetic procedures such as astigmatic keratotomy and limbal relaxing incisions.
Mistake 3. Inducements and violations of anti-trust laws
In a previous OSN column (Oct. 1, 2006, page 28), Mr. Zimmerman stated the following:
“Federal criminal and civil statutes prohibit offering or paying anything of value to induce a person to purchase a service or item covered by a federal health care program. Thus, for example, routine waiver of deductibles and coinsurance amounts otherwise owed by a Medicare beneficiary are considered to be an improper inducement to purchase Medicare-covered services. Persons who violate these laws are potentially subject to criminal and civil sanctions.”
Most facilities are audited continually for clinical and medical issues in order to maintain accreditation. However, surprisingly few engage in reimbursement and compliance audits – it is something that should be done.
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Mistake 4. Cosmetic procedures
When cosmetic procedures are performed either alone or in conjunction with other covered procedures, the facility fee has to be billed to the patient. If not, this also could be considered an inducement to the physician to bring cases to that specific facility. This applies to physician owners as well as physicians who are just using the facility. Be careful in differentiating procedures that cannot be billed to the patient (covered procedures that are not on the list) from those procedures that should be billed to the patient (cosmetic blepharoplasty).
Mistake 5. Chart documentation
Mainly errors of omission rather than errors of commission fall into this category. Each ASC chart should be able to stand on its own in terms of audit – and that includes documentation that may already be in the physician’s patient chart but is not placed in the ASC chart. Most of these deal with medical necessity issues.
The ASC chart should include the ADL (Activities of Daily Living) form for all cataract and YAG laser procedures. One clever practitioner made computerized forms that had two items (“Could not read well enough” and “Could not see well enough to drive”) checked off. The patient signed the document. In an individual audit, a specific chart might have withstood an auditor’s scrutiny; however, in this case, the auditor saw immediately that each ADL form was identical. Oops — go directly to jail, don’t pass go and don’t collect $200.
I recommend that a copy of the physician’s office note for the day that the surgery was scheduled be incorporated into the ASC chart. Medical necessity issues are documented by doing this.
Either an Advanced Beneficiary Notice or Notice of Exclusion of Medicare Benefits form needs to be used when billing for procedures that may be denied The former is to be used when there is a question of medical necessity (possibly cosmetic blepharoplasty) whereas the latter is to be used when procedures are statutorily excluded from the Medicare program (presbyopia-correcting IOLs).
For more information:
- Riva Lee Asbell can be reached at www.rivaleeasbell.com.
- CPT codes, copyright 2007, American Medical Association.