Health Information Management

OIG review finds outlier payment errors in one of the nation's top hospitals

APCs Insider, August 27, 2003

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Vol. 4, No. 34



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THE MONITOR'S ADVISORY BOARD

Keith Siddel,
MBA, PhD (c),
president, CEO
HRM, Hospital Resource Management

Andrea Clark
RHIA, CCS, CPCH
president
Health Revenue Assurance Associates

Cheryl D'Amato,
RHIT, CCS,
director, health information management
HSS, Inc.

Julie Downey,
CPC, CPC-H,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,
RHIT, CPUR,
Independent
Consultant

Julia R. Palmer
MBA, RHIA, CCS,
president, Health Information Management Division
HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System


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TIP OF THE WEEK

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OIG review finds outlier payment errors in one of the nation's top hospitals

A recent Office of the Inspector General (OIG) review of a Chicago-based academic medical center showed it had received inaccurate OPPS outlier reimbursement.

But not by much. Out of $83,805 worth of outlier payments reviewed, Rush-Presbyterian-St. Luke's Medical Center was overpaid by $7,726 and underpaid by $7,752. The facility is required to return the overpayment, and will attempt to recoup the loss of the $7,752, resulting pretty much in a wash.

But all hospitals may not be this lucky. Take notes and learn from Rush's experience.

The OIG reviewed Medicare outpatient claims with outlier payments of at least 85% of the total claim reimbursement for services performed August 1, 2000 through June 30, 2001.

Out of a sample of 50 claims, 38 were reimbursed incorrectly. The 35 overpayments were not the fault of the facility, however. Its fiscal intermediary's claim processing system had "an outlier pricing issue" which caused these errors.

Rush did make a mistake when it did not use HCPCS codes when billing for implantable devices, creating the three underpayments. The hospital would have received higher reimbursement if the HCPCS codes had been correctly used.


Your APCs Weekly Monitor is a free weekly e-zine from HCPro, publisher of Briefings on APCs, the monthly newsletter devoted entirely to managing under APCs, and the newsletter, APC Answer Letter, with answers to readers' questions about coding for APCs.

The Monitor is a complimentary companion publication with a specific mission: to provide answers to your tough questions about the APC regulations.

If you have a question about APC coding that you would like addressed in the Monitor, post it on our Web site at himinfo.com. Each week, our team of experts answers a question that will appeal to the majority of readers. The elected question and the corresponding answer are delivered to your inbox every Friday.


TODAY'S TOPIC: Wound coding

Question: For a patient seen in the wound center for wound treatment using debridement, do we code and bill both a visit code and the debridement CPT code? For a patient seen in the burn center for burn treatment with whirlpool and dressing changes, do we code and bill both a visit code and the whirlpool/dressing change code?

Answer: When a patient is seen in the wound care center for wound treatment via debridement, the coding depends on the circumstances of the visit.

Was the patient presenting specifically for the debridement or was the patient presenting for evaluation of the wound? If for debridement, only the wound debridement code would be used.

If the patient was presenting for evaluation of the wound and after evaluation it was determined that debridement was necessary, both the E/M code and the debridement codes should be billed, since the patient was evaluated and the management was determined based on that evaluation.

Make sure the debridement was medically necessary. The documentation in the medical record should be evaluated to determine how to code each individual case.

When the patient is presenting specifically for whirlpool with dressing changes, only the whirlpool should be coded. If the patient presents for evaluation and it is determined that whirlpool treatment is necessary, an E/M visit code is billed.

Dressing changes should not be separately billed. If only a dressing change is performed, an E/M code should be assigned.


PAY PER VIEW: Doctors aren't the only providers with documentation deficits

In HIM and compliance circles, we're always discussing the lack of thorough documentation by physicians. But documentation problems often go beyond the doctor-to nurses, therapists, and case managers.

Read more HERE. The cost is $10. Medical Records Briefing subscribers have free access via their online subscriptions.

ASK THE EXPERT: We have been reporting the new 2003 CPT codes and noticed a distinct difference in coding and documentation instructions for excision lesions. How will this affect our APC payment?

Read HERE for the expert's answer!

Coding and Compliance Feature Article of the Month: Cross-training, certification focus push Florida coders up the ladder


Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.




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