REVENEWS ARCHIVE
RAC Findings
November is here and hopefully you are preparing to spend Thanksgiving with your family and friends! Although the busy holiday season is here, the Recovery Audit Contractors (RACs) are continuing to review healthcare claims for improper payments. In this article, we will review some recent findings related to Physicians.
Incorrect Facility vs. Non-Facility Reimbursement
Physicians who bill for services provided to a Medicare beneficiary in a facility setting need to be aware of this finding. Medicare Part B reimburses physicians at an increased rate for some services performed in their offices to account for the increased expense that physicians incur when performing services in their offices. If, however, physicians perform these services in a facility setting, such as an inpatient facility, Medicare reimburses the overhead expenses to the facility and the physician is reimbursed at a lower rate. An improper payment can occur when physicians bill these services with an incorrect place of service based on the setting in which the services were provided.
Below are two examples:
Case A: An 84 year-old female was admitted as an inpatient on June 21, 2010 and was discharged on July 19, 2010. The physician billed CPT code 99291 (Critical Care first hour) for date of service June, 23, 2010 with a place of service code 11 (Office). CPT code 99291 has a site-of-service differential. Code 99291 has a non-facility allowed amount of $260.50 and a provider paid amount of $208.40. It was confirmed that on June 23, 2010, the patient was not on a leave of absence from the hospital. Therefore, the correct place of service code for this service date is 21 (Inpatient Hospital).
CPT code 99291 is adjusted to pay at the facility rate by applying the correct place of service code of 21. The allowed amount for 99291 for the facility rate is $218.27. The new provider paid amount is $174.62. This results in a total recouped amount of $33.78.
Case B: A 60 year-old male was admitted as an inpatient on July 31, 2010 and was discharged on August 4, 2010. The physician billed CPT code 90801 (Psychiatric Diagnostic Interview Examination) for date of service August 2, 2010 with a place of service code 11 (Office). CPT code 90801 has a site-of-service differential. Code 90801 has a non-facility allowed amount of $159.42 and a provider paid amount of $127.54. It was confirmed that on August 2, 2010, the patient was not on a leave of absence from the hospital. Therefore, the correct place of service code for this date is 21 (Inpatient Hospital).
CPT code 90801 is adjusted to pay at the facility rate by applying the correct place of service code of 21. The allowed amount for 90801 for the facility rate is $130.94. The new provider paid amount is $104.75. This results in a total recouped amount of $22.79.
Lessons Learned:
Physicians should become familiar with the CPT/HCPCS codes with site-of-service differentials. The physician fee schedule includes some procedures that have a separate Medicare fee schedule for a physician’s professional services when provided in a facility and in a non-facility. CMS provides both fees in the Medicare Physician Fee Schedule Database (MPFSDB). Information about the Physician fee schedule can be found at http://www.cms.gov/PhysicianFeeSched/ on the CMS website.
The following CPT codes have the greatest number of improper payments based on dollars paid or number of claims paid:
- 99291: Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
- 85097: Bone marrow, smear interpretation
- 96118: Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
- 90801: Psychiatric diagnostic interview examination
Physicians should become familiar with the “Place of Service Code Overview” located at http://www.cms.gov/place-of-service-codes/01_Overview.asp#TopOfPage on the CMS website.
Physicians should review the “Medicare Claims Processing Manual,” Chapter 12, paragraph 20.4.2 and Chapter 26, Section 10.5-Place of Services Codes (POS) and Definitions, which are available at http://www.cms.gov/manuals/downloads/clm104c26.pdf on the CMS website.
Physicians should educate their billing staff on the correct place of service code for the services performed. Reviewing MLN Matters article SE1104 should assist billing staff. This article can be found at http://www.cms.gov/MLNMattersArticles/downloads/SE1104.pdf on the CMS website.
For additional information, click on the link below:
http://www.cms.gov/MLNProducts/Downloads/MedQtrlyComp_Newsletter_ICN907163.pdf