How Coding Errors Lead to Overpayment Recoveries

CMS offers advice through its Medicare Learning Network Connects bulletin to avoid coding errors.

Mistakes happen, and errors do occur in the coding industry. The May 24 Centers for Medicare and Medicaid Services (CMS) Medicare Learning Network (MLN) Connects bulletin included provider compliance information that is noteworthy and important to read through.

The following is directly from that publication:

In two recent reports, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) cited significant issues leading to coding errors on Medicare hospital claims:

• Hospitals Nationwide Generally Did Not Comply with Medicare Requirements for Billing Outpatient Right Heart Catheterizations with Heart Biopsies (March 2017):

The OIG found that hospitals often use modifier -59 incorrectly when billing for outpatient right heart catheterizations with heart biopsies, which leads to significant overpayments and overpayment recoveries on claims for these services.

• Medicare Improperly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Consecutive Hours of Mechanical Ventilation (June 2016): 

The OIG found that hospitals often use incorrect procedure codes when billing for mechanical ventilation.

Use the following resources to bill correctly and avoid overpayment recoveries:

• OIG Reports Highlight Hospital Billing Issues MLN Matters® Special Edition Article
• Proper Use of Modifier 59 MLN Matters Special Edition Article
• Specific Modifiers for Distinct Procedural Services MLN Matters Article
• Medicare Claims Processing Manual, Chapter 3, Inpatient Hospital Billing: Section 10, General Inpatient Requirements

• Medicare Quarterly Provider Compliance Newsletter, Volume 2, Issue 1

• Medicare Quarterly Provider Compliance Newsletter, Volume 7, Issue 4

The OIG reports can be helpful in meeting coding compliance and integrity. This also provides insight into coding and documentation issues so one can include these specific areas in their internal and external audit plan as well as your educational program and materials.

Information regarding modifiers is always something to review, as there have been compliance issues in this area of coding for many years now. Again, include modifier accuracy in your audit plan and review.

Although the Medicare Claims Processing Manual is a great resource and the billing or patient financial service department may receive and retain this document, often the coding professional has not read over the manual section(s) regarding coding and documentation, so this is a great reminder to begin that process and continue on an ongoing basis.

It is important and essential for you to have a “coding compliance program/plan” in place and operational. The key aspects to your coding compliance program would be the following:

• Mission, Vision, and Code of Ethics
• Leadership, Accountability, and Communication
• Policies and Procedures (written)
• Education and Training
• Auditing and Monitoring (Internal and External)
• Corrective Action and Discipline

You have all heard this phrase: “If it’s not documented, then it never happened.” This refers to a service or procedure which must be substantiated (documented) within the medical record and, yes, included in the Electronic Medical Record (EMR) for the payers (and auditors) to accept the claim for that service/procedure. Another phrase we hear and take note of in relation to diagnosis is “If it’s not documented, then it didn’t exist.”

As HIM Coding and CDI (Clinical Documentation Improvement) professionals, we need to stay on top of regulatory compliance alerts like the ones from CMS and the OIG. This will help us detect, correct, and prevent errors from occurring in the future.

Comment on this article