Reducing Medicare Payment Denials and Reductions

Posted on December 7, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

Start with Diagnosis Coding Documentation Guidelines

By Patricia A Trites; MPA, CHBC, CPC, CHCC, CHCO, CMP™(Hon) 

[CEO: Healthcare Compliance Resources, Inc]

A 2003 audit of Medicare claims by the Office of the Inspector General (OIG) found that Medicare fee-for-service payments that did not comply with all of the Medicare laws and regulation was $13.3 billion in fiscal years 2001 and 2002. 

Improper payments in 2002 occurred mostly in three areas: medically unnecessary services (57.1 percent), documentation deficiencies (28.6 percent) and miscoding (14.3 percent).

And so, how do you prevent or reduce denials or reduction of payment when claims are adjudicated as “not medically necessary”?  

Begin by following the diagnosis coding documentation guidelines, which are: 

  • Code to the ultimate specificity. There is a significant difference between 716.90, Arthritis, Type and Site Not Otherwise Specified, and 716.39, Menopausal Arthritis, Multiple Sites-Joints.
  • Use Additional Codes and Underlying Disease Codes. Many conditions require, by medical-record coding rules, that you use two ICD-9 codes and that these codes are put in the appropriate order. For example, 533.30 Peptic Ulcer-Acute and Without Obstruction, and 041.86, Due to Helicobacter Pylori Infection.
  • Use multiple codes to fully describe the encounter. This includes coding any additional co-morbidities and/or signs and symptoms that affect the patient’s current encounter.
  • Choose the appropriate principals diagnosis and properly sequence secondary codes. List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. Then list additional codes that describe any co-existing conditions or symptoms.
  • Avoid using .8 and .9 “catch-all” codes. In the ICD-9 system, descriptions and digits are provided for times when a physician lack information about a patient’s exact condition or diagnosis. The codes commonly end in .8 or .9 and are commonly referred to as catch-all codes. Under Medicare coding guidelines, these codes should be used only when the specific information required to code correctly is unknown or unattainable. 

Do you use a professional coder in your healthcare entity; or do you do-it-yourself?

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2 Responses

  1. Jane, on June 14, 2010 at 11:36 AM said:

    Medicare Compliance Will be Required Under New Healthcare Reform Law

    Whether physicians code their own charts or coders do it for them, the stakes are high for scrutiny of coding and documentation. Under the health reform law, every physician group will be required to have an effective compliance program as a condition of Medicare and Medicaid enrollment, and auditing is a core element of an effective compliance program.

    “Pulling in a consultant once a year to teach doctors about documenting and coding would not, by itself, be an effective auditing and monitoring program,” says attorney Ed Gaines, chief compliance officer for Medical Management Professionals.

    Recovery audit contractors (RACs) and zone program integrity contractors (ZPICs) also are targeting physician billing.

    Source: Nina Youngstrom, Report on Medicare Compliance [6/4/10]

    Like

  2. Hope R. Hetico RN MHA, on June 28, 2012 at 3:23 PM said:

    Providers May Have Wiggle Room On 60-Day Overpayment Deadline

    Although the health reform law requires providers to return Medicare and Medicaid payments 60 days after identifying them, knowing when to begin counting can make or break compliance. Some attorneys say providers can start later than they may think. For example, providers may be able to argue that the 60-day clock on identifying Medicare or Medicaid overpayments doesn’t start ticking until they bring in outside experts to nail down the amount and cause of the error, says Cleveland attorney Alan Schabes, with Benesch, Friedlander, Coplan & Aronoff.

    While consultants shouldn’t be used to play a cat-and-mouse game with the overpayment-return mandate, “if there’s a legitimate reason for bringing someone from the outside, I think that a provider would have a basis to argue the 60 days shouldn’t start until after the outside party has come in,” Schabes says. A February regulation proposed by CMS to interpret the law (RMC 2/20/12, p. 1) says that when providers learn about a potential overpayment, they are obliged to make a “reasonable inquiry” to determine whether an overpayment exists.

    Source: Nina Youngstrom, Report on Medicare Compliance [6/18/12]

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