Yeast Allergy Symptoms: Allergy Coding « Yeast Infection Treatment …

Yeast Allergy Symptoms:

Anallergy isan abnormal reaction of the human immune system, when it wrongly identifies certain allergens such as pollens, foods, drugs, dust, etc to be harmful foreign substances and produces antibodies against them. When these antibodies are produced in excess, they release histamine and other chemicals in your body, which in turn results in some allergic reaction. Allergy manifests itself most frequently in the respiratory tract or the skin – these manifestations of allergic conditions include allergic rhinitis, eczema, hives and hay fever. Severe reactions include violent cough, cyanosis, fever, pulse variations, convulsions and collapse. Allergic reactions may be acute, chronic, immediate or delayed and the agent causing the allergy is to be identified to provide apt treatment – avoidance, medication or immunotherapy treatment.

Allergy coding involves coding procedures that come under allergy testing, immunization and desensitization. Coders tend to be confused as regards the various types of allergy testing, those who can do the testing, how allergy shots can be properly billed, and so on. Coding for allergy is made more complex with details such as the allowed limits, combinations, units and same day evaluation/management services.The patient’s medical record must clearly document the medical necessity for each test performed, the test results, unfavorable reactions if any to each test, for each date of service submitted on the claim.

Allergy Testing Coding

To know if you are allergic, you need to be tested for inhalants known to cause allergies, for food allergies and so on. Allergy testing is categorized into in vivo and in vitro methodologies. Allergy testing is covered only when it is considered ‘medically necessary’ and is ordered by a physician. The physical examination should indicate allergic signs/symptoms. Allergy testing is also covered when a diagnosis such as asthma, indicative of an allergy has been made.Covered CPT codes include the range 95004-95199. Investigational allergy tests are not usually covered.

In vivo testing includes allergy skin testing:

Percutaneous test (scratch, prick or puncture test)
CPT codes covered: 95004, 95010

Percutaneous test is the allergy sensitivity test most frequently performed; however, the following cutaneous and mucous membrane tests are sometimes included in an allergy evaluation:

Intracutaneous test (intradermal test)
CPT codes covered: 95015 95024 95027 95028

Photo Patch test
CPT codes covered: 95052; the number of tests has to be specified

Patch or application test(s)
CPT code covered: 95044; the number of tests has to be specified

Photo Tests
CPT code covered: 95056

Bronchial Challenge Test
CPT codes covered: 95070 95071 Other CPT codes related to the CPB: 94150 94200 94240 94350 94360 94621 94680 94681 94690 94720 94770

Exercise Challenge Test
CPT codes covered: 94010 94060 94070 94150 94200 94240 94350 94360 94375 94620 94621 94680 94681 94690 94720 94770

Food ingestion challengetest
CPT code 95075

Opthalmic mucous membranetests
CPT code 95060

Direct nasal mucous membrane test
CPT code 95065

Serial endpoint titration (SET) test (eg, intradermal dilutional testing [IDT]
CPT code covered: 95027

Provocative test (for example, Rinkel test)
CPT code: 85078

Percutaneous and intracutaneous allergy tests are accepted as medically necessary and are covered by most insurance providers. However, there are certain limitations imposed:

The number of scratch, puncture or prick allergy tests eligible for reimbursement per year is 70 (CPT code 95004)
The number of intracutaneous allergy tests eligible for reimbursement per year is 40 (CPT codes 95024 and 95028)

SET testing is considered medically necessary and is covered up to 80 tests per year (CPT codes 95010, 95015 and 95027).

Patch test, photo patch test, mucous membrane test, bronchial inhalation challenge test, and food ingestion challenge test are also considered medically necessary and covered for the diagnosis, evaluation and treatment of allergies. Other allergy testing procedures including sublingual testing, provocative testing, and Rebuck skin window test are not covered because they are considered experimental or investigational. These are to be reported with the CPT code number 95199.

Tests such as Leukocyte histamine release, Prausnitz-Kustner test, Cytotoxic food testing (leukocytotoxic test, Bryans test) and Conjunctival challenge testing (ophthalmic mucous membrane test) are usually excluded from reimbursement.

In vitro testing involves blood tests to identify the presence of specific IgE antibodies to a particular antigen. Procedure codes for allergy tests are usually reimbursed per test for the total number of tests performed.

Allergy laboratory testing includes CPT codes 86000-86999. 86003 and 86005 are codes used to signify allergen specific IgE determinations. RAST, MAST, FAST, ELISA, and ImmunoCAPtests are indicated when percutaneous testing of IgE-mediated allergies cannot be done. Radioallergosorbent testing for allergies has to be reported with code 86003 (allergen specific IgE; quantitative or semiquantitative, each allergen).Service providers reporting with this code have to give supporting documents to validate the medical necessity for the allergy testing procedure, explaining why other routine allergy tests were unsatisfactory. These tests are reimbursed in the following situations:

When skin tests cannot be performed routinely due to conditions such as infancy, extensive eczema, icthyasis or dermographia
When the skin test has proven inconclusive
When the patient is under medication that might interfere with skin testing, but can’t be asked to discontinue
When the patient has systemic reaction to skin testing

If medical necessity is not validated, code 86003 might not be reimbursed. Apart from CPT codes, the claims should also contain all relevant ICD-9 and HCPCS codes for full reimbursement.

Allergy Immunotherapy Coding

Allergy immunotherapy includes avoidance therapy, pharmacologic therapy and immunotherapy. Avoiding the allergen responsible for causing allergy is the most effective treatment. Allergy immunotherapy also known by the terms hyposensitization, desensitization, allergy injection therapy, or “allergy shots” is recommended for patients

In whom the allergens triggering the reaction are not easily avoidable
The allergy is IgE mediated
The allergy is not effectively controlled by medication

Allergy immunotherapy desensitizes the patient to the allergen that caused the allergy. It protects the patient against the allergic symptoms and inflammatory reactions. Allergy shots are usually provided in a medical setting and contain increasing doses of the allergen. The healthcare provider must accurately document the allergy shots given to the patient to be properly reimbursed. To avoid claim denials, it is important that the patient is examined by a physician; in addition, the examining physician has to prepare the antigens, develop a treatment plan and dosage schedule.

In allergy immunotherapy, the CPT codes covered include 95115-95170, 95199. If other identifiable services are given during office visit, office visit codes can be used in addition to allergen immunotherapy codes.

Some Important Considerations

When percutaneous or intracutaneous sequential and incremental injections (95010, 95015 or 95027) and single injection (95004 or 95024) tests are provided on the same date, all these codes may be reported if the tests are different allergens or different dilutions of the same allergen. The number of separate injections are to be reported, do not report both a single injection test and a sequential and incremental injection test for the same dilution of an allergen. SET testing can be reported and will be reimbursed on a per allergen basis.

The patient’s medical record must clearly document the medical necessity for the treatment provided. Medicare Benefit Policy Manual provides details of services covered, codes and other relevant details helpful in accurate coding. A standardized CPT code is assigned for every medical procedure and task. Medical coders have to be thorough with the reimbursement policies of different insurance providers

Allergy Coding - Outsource Strategies International (OSI) is a leading medical coding company in the US committed to providing fast and efficient medical coding services.

HRchitect Tech Vendor News: HealthcareSource Acquires Nursing …

Acquisition adds 142 nursing courses to HealthcareSource’s eLearning Library and gives Bluedrop rights to resell HealthcareSource content internationally

Woburn, MA –  July 23, 2014 HealthcareSource®, the leading provider of talent management solutions for the healthcare industry, today announced the acquisition of 142 custom developed, continuing nursing education (CNE) approved courses from Bluedrop Learning Networks, a global leader in eLearning solutions. Terms of the acquisition also allow Bluedrop Learning Networks to resell HealthcareSource proprietary content internationally through its distribution channels.

The addition of these courses to the HealthcareSource eLearning Library℠ expands the HealthcareSource-owned library of CNEs to more than 200 courses, which are in addition to the several hundred other healthcare compliance and clinical education modules HealthcareSource owns. Through the addition of these 142 courses, the eLearning Library offers more than 2,800 hours of pre-approved continuing education hours.

“The timing of this sale is advantageous for both HealthcareSource and Bluedrop Learning Networks,” said Emad Rizkalla, founder and CEO of Bluedrop Learning Networks. “As HealthcareSource is investing in deepening and expanding its eLearning Library, Bluedrop Learning Networks has decided to focus on other core business lines. The reseller agreement allows us to leverage the value of the HealthcareSource brand to provide an expanded library of content to international markets.”

The eLearning courses included in the acquisition integrate medical and technical information with practical situations, stories from real world clinical experiences and the use of medical animations, interactivities, and 3D graphics. They cover a wide variety of high-demand and popular nursing-specific topics and include the most complete library for nursing leadership development available in the market.

“We are pleased to expand our CNE offerings to more than 200 courses and add additional eLearning content in the nursing specialty categories of leadership, emergency nursing, critical care, neurology, and obstetric-neonatal,” said Michelle Leavitt, Director of Courseware and Product Strategy at HealthcareSource. “Additionally, the reseller agreement enables Bluedrop Learning Networks to market and sell our newly-expanded CNE offering through international channels.”

The eLearning Library, a part of the HealthcareSource Quality Talent Suite℠, contains more than 4,000 courses in clinical and non-clinical compliance, coding and reimbursement, continuing education, clinical reference, and other areas. In addition, the eLearning Library has partnerships with industry-leading organizations to provide users with access to award-winning, world-class, online education.


To learn more about HRchitect and how we can help your organization, please visit HRchitect is the leader in HCM systems strategic consulting.  As the premier Human Capital Management (HCM) Systems consulting firm, we offer end-to-end HR technology consulting services focused around strategic planning, evaluation/selection, project management and implementation of HR systems, Talent Management Systems, Talent Acquisition Systems, and Workforce Management software. After more than 17 years in business working on over 2100 successful engagements for more than 900 clients across the globe, HRchitect is a name you can trust for all of your organization’s HCM technology-related consulting needs.

Matt Lafata, HRchitect

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Procedure codes with modifier 22 – Medical Billing and Coding …

What is the overall Billing process?

The physician doesn’t get paid for his services immediately after they are rendered. Majority of the patients have insurance coverage and details of such coverage are provided to the physician before treatment. It is the responsibility of the physician to submit claims to the insurance company and get paid for his services. Submitting Claims and getting paid is a lengthy process and involves a lot of rules and regulatory systems and is very complicated. The physician needs to adhere to all these rules before submitting claims. This is the concept of Medical Billing. Sometimes the physician cannot provide his entire attention to this activity. He entrusts this activity to Billing Companies. This is a process of the physician providing rights to Billing Companies to bill Medical Insurance claims in order to save his time energy, and money.

After the provider renders services to the patient, the billing company will submit bills to the insurance company/ payer, using the insurance information that was last provided, as well as information about the reason for the examination, and the exact type of procedure performed.

Medical coding is the process of converting Medical terms to numeric code and it required Medical knowledge skills.

Medical billing is the process of submitting the claims and get paid behalf of provider.

I have listed the important process in Medical Billing. Each process is very important.

1. Insurance verification.

2. Demo and Charge entry process.

3. Claim submission.

4. Payment posting.

5. Action on denials or Denial management or Account receivables.

Insurance verification

Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance details by calling insurance or through online verification. If this department works well, we could resolve more problem. We have to do this even before patient appointment.

Demo and Charge entry process

Demographic entry is nothing but capturing all the information of patients. It should be error free.

Charge-entry is one of the key departments in Medical Billing. Key department?? Yes, that’s true. It is the keying-in department in Medical Billing. After receiving the super bills from the Doctor’s office, it gets passed through the coding department, and then comes to the charge-entry department.

A Charge-entry person also has one other vital role to perform. That is, to look-up the codes entered in the claim, and to assign the relevant charges for those codes.

Claim submission Process

The next step after demographics and charge entry is claim generation. Claims may be paper claims or electronic claims. There are various types of forms for paper claims. The most widely used form is Health Care Finance Admin-1500 designed by the Health Care Financing Administration.

Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company’s computer system or to the clearing house.

Payment Posting Process

Once the claims reach the carriers and they complete processing, they issue a check and prepare an Explanation of Benefits . The checks and the Explanation of Benefits would be sent to the pay-to address with the carrier or in the Health Care Finance Administrators.

In this processing we have accounted the money into the account as per the Explanation of Benefits. Now a days we are using Electronic payment posting also.

Action on denials or Denial management or Account Receivables

This is a most important function in the process flow of data. Unless this is taken care of, insurance balance will only be on an upward trend.

Problem in Medical Billing

•Inaccurate or lack of coding

• Incomplete claims

• Lack of supporting documentation

• Poor communication with the payer

• Not billing for services rendered

* Not being follow up AR balance claims

The person who is doing this process will be called Medical billing specialist.

Who is Medical Billing Specialist.

Medical billing Specialist is the one who is handling the below process and having well knowledge in each and every process.

* Insurance verification process

* Patient demographic and charge entry process.

* Submitting the claims by electronic as well as paper method. Tracking various claim submission report.

* Payments posting process for insurance as well as patient.

* Denial management.

* Insurance followup management.

* Insurance appeal process.

* Handling patient billing inquiries.

* Patient statement process.

* Preparing monthly reports such as revenue report and account receivable report and as per the provider requirement.

Medical Billing Specialists are in charge of reviewing patient charts and documents. They prepare and review all medical insurance claims based on the rules and regulations of insurance companies. Medical Billing Specialists also review insurance communications, payment and rejection notices to properly track all claims and payments.

Medical Billing specialist Professional

If a person is computer literate he is a fit enough candidate to take up the profession of medical billing and medical coding. However he will need to be trained and be aware of a lot of new information before he can start working effectively. He has to learn about the medical billing software and must be familiar with and master the various commands used while working with it.

Who are medical coders and how is it related to medical billing? Medical billing is a sub specialty of medical coding. Medical coding is the first step in the billing process. All patient records are maintained using the ICD-9 index system so that it is compliant with the federal rules.

A medical Biller’s most important skill includes filling up of the various medical forms correctly without any mistakes what so ever. All information required should be complete without any mistake at all. And the work will be include the following

Patient demographic entry

Insurance enrollment

Charge entry

Insurance verification

Billing and reconciling of accounts

Payment posting

Insurance authorization

Medical coding

Scheduling and rescheduling

Account receivable follow-ups and collections

Is it worth taking a medical billing program?

Usually don’t spend too much cost on Medical billing program because the program will not do anything with real experience. What you learn from these kind of program will not be going to match with when you are working in the real environment. Hence just use as the start kind of program and get the real time experience even in small salary and later you can come up with more demanding one.

Problem of In House Processing of Medical Claims

Medical claims are generally very complex and have long extended details. While processing medical claims, one has to be highly critical and do efficient follow-up in order to get results. The process requires a lot of time and effort. And even after all this, there can be cases where files get lost or a small error can ruin the entire lot and everything has to be re-submitted again. Usually practice staff can be held up with lot of current work rather than submitting the claim and resubmitting the corrected claim hence it will lead to time delay on payment flow and it will affect all the relationship with in the practice. Even cost wise is also not effective when compare to outsourcing.

Advantage of Medical Billing Outsource

Medical Billing Company helps you in managing all your billing requirements proficiently. By choosing right medical billing company, you can get benefit such as improved financial strength.

Medical Billing task is very tedious and time consuming. However, billing must require more accuracy and special attention to strengthen the financial condition of clinical or hospital. You can do this task at own or assign to clinical staff but you have to be pleased with low patients satisfaction. Medical billing company can help you in supportive task. By efficient medical service, you will get highly satisfied patients.

A Medical Billing service can improve the efficiency of your billing system, reduce denials, cut down operating costs, boost reimbursements and save valuable time that can be devoted to patient care. These services are better equipped to adapt to continuously changing billing codes and industry requirements.

* Prince is low compare to doing it in house

* Dedicated Highly Skilled Professionals

* No need to maintain the hardware . Ability to perform Medical Billing remotely, using the software of your choice

* Usually Maximum reimbursements and fewer denials

* Accuracy is high when compare

* Faster transaction

Question need to ask when Medical Billing Outsourcing

1. Check with their referral and how long they are doing this business.

2. Are they HIPAA compliance

3. Where they are doing their work. If possible just visit there.

4. Data security.

5. Compare the price with others.

6. what are the reports they will provide

7. Your specialty wise question

8. Their software skills.

Services and process involved in Medical Billing

* Coding ( CPT, ICD-9, and HCPCS)

* Patient Demographics Entry

* Charge Entry – All specialties

* Payment Posting (Manual and Electronic)

* Payment Reconciliation

* Denials/rejections analysis, re-billing

* Accounts Receivable Follow-up

* Systemic A/R projects, re-billing

* Collection Agency Reporting

* Refunds

Medical Billing Salary Range

Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. However, the geographic location also plays a role in pay scale. For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.

Most of the medical Billers are paid hourly, rather than annually. While Biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. There is lots of fraud going on in this field. These spammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.

Selecting Medical Billing Software – 10 things to consider

1. The first step is to evaluate your needs. And when evaluating different systems look for a package that goes one step ahead of billing. Choose a medical practice management system MPP. This will handle considerably more that just medical billing.

2. Determine whether the system handles electronic transmission of claims, direct billing for patients, co-pays, co-insurance, and expenses not covered by insurance.

3. Weigh the pros and cons of different medical billing systems and ask to see a system in operations. Always check out the references yourself.

4. Look for a medical billing management system that is user friendly. When a vendor demonstrates get your office staff to be present. This way you will be able to check how the software functions. Any software must be easy to use to be productive. The system should be fool proof.

5. Ask whether the medical billing software is a traditional system, one that will work on your office computers or an application service provider system (ASP), one that will process data at the software company’s data center.

6. Always get quotes from at least three medical billing software providers.

7. Ask whether they are offering an evaluation period or trial. This will enable you to know in actuality whether the system works or not.

8. Find out about training your office people, up-gradation of system, and whether the software is compatible with your office computer systems

.9. Find out whether the system will handle appointment scheduling, maintenance of records and so on apart from electronic medical records, SOAP notes, and billing. Choose a system that is comprehensive.

10. An ideal Medical Billing software system must include aspects like payment posting, reconciliation; follow up, secondary submission, and patient billing.Choose a transparent billing system that enhances your office efficiency. Install a system that you can use not one that will lead to frustration and problems.Medical billing systems must free your time and that of your office staff not make you run in circles. Choose a system with care.

The Top 4 Tips to Code Medical Time-based Services Appropriately …

Many services within the CPT codebook include a time component. Except where CPT guidelines state otherwise, follow these four tips to ensure you’re reporting time-based services correctly.

1. Count only included services

When calculating time spent performing a procedure or service, include only those items specifically detailed in the code descriptor. For example, when reporting critical care services (e.g., 99291-99292), you may include the time spent interpreting cardiac output measurements or chest X-rays, performing ventilatory management or vascular access, and other services enumerated within CPT as inclusive of critical care. You may not count toward critical care the time spent performing other, separately reportable services (e.g., endotracheal intubation for airway support, 31500).

Carefully review CPT guidelines and code descriptors to determine which activities you may count toward the time of a particular service. Each code category or descriptor may include different components within a time-based code. For instance, critical care includes floor/unit time, in addition to time spent at a patient’s bedside. I contrast, when calculating time for prolonged services 99354-99357, you may count only “face-to-face” time. Many time-based services include only that time spent “face to face” with the patient. Count time away from the patient only if the code descriptor or other CPT guidelines specifically allow you to do so.

Bonus tip: As a best practice, when providing time-based services, you should document start and stop times, as well as the total time of service.

2. Pass the “midpoint” before billing a time-based service

If a code describes the “first hour” of service, you must provide and document at least 31 minutes of service. Likewise, if the unit of service is 30 minutes, you must perform and document at least 16 minutes of service (and so on). If the service does not meet the minimum time required, either you may not separately report the service, or you should report an (other) appropriate evaluation and management service code. For instance, if you provide fewer than 30 minutes of critical care (99291), CPT instructs you to report “appropriate evaluation and management codes.”

Some codes describe “24-hour services.” In most cases, you must document at least 12 hours of service to report such codes. For services lasting fewer than 12 hours, you may need to append modifier 52 reduced services. Be sure to review CPT guidelines before assigning codes or modifiers.

3. Select the “closest” code

Per CPT guidelines, “When codes are ranked in sequential typical times and the actual time is between to typical times, the code with the typical time closest to the actual time is used.”

This rule applies when reporting evaluation and management services using time — rather than the key components of history, exam, and medical decision-making — as the determining factor in the level of service (e.g., if counseling and/or coordination of care comprise more than half the encounter). In such cases, you should use CPT “reference times” to determine an appropriate evaluation and management service level.

For example, a Level 3 established patient outpatient visit (99213) has a reference time of 15 minutes, and a level 4 service (99214) has a reference time of 25 minutes. When reporting a time-based evaluation and management service lasting 19 minutes, you would report 99213 because it has the closest reference time.

4. Use the initial DOS for continues services

CPT states, “For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided continuously.”

For instance, if intravenous hydration begins at 10:30 p.m. and lasts until 1:30 a.m. the next calendar day, you would report 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour once and 96361 …each additional hour (List separately in addition to code for primary procedure) twice. You would not report a new “initial” service (96360) on the new calendar date, unless that service truly represents a different session or encounter with the patient.

G. John Verhovshek, MA, CPC, is managing editor at AAPC, the nation’s largest training and credentialing organization for the business side of healthcare.

Staying Updated On Cpt Code Changes – InformationBible

It’s of critical importance for health care professionals and medical personnel to remain up to date on all changes to the CPT Code. The CPT code is the Current Procedural Terminology code set, and it is managed by the American Medical Association (AMA). The AMA appoints a committee known as the CPT Editorial Panel to handle it, which is used by a variety of health care specialties to make communication of medical terms consistent and uniform. It allows patients, physicians, organizations, and payers to communicate clearly and consistently in regards to treatments.

Changes to the code released in new editions which are available annually. These new additions come out each year in October. There are standard and professional editions of the CPT code. Unlike the ICD-9 and ICD-10 code sets, the CPT set does not refer to diagnosis of conditions but rather to the treatments and services used by medical professionals in the treatment of their patients. While the ICD code sets do have some codes for this purpose, they are not utilized in outpatient settings, while CPT codes are. The CPT code set is known as level one of the health care procedure coding system, and identified as such by the Centers for Medicare and Medicaid Services, and thus is very important for all practitioners.

The code set is divided in a number of different categories. Category I consists of codes used for evaluation and management, anesthesia, surgery, radiology, pathology and laboratory, and medicine. Each of these subsections is broken down in a logical and intuitive manner so that professionals in their respective fields can identify which type of code is being
used. For example, the codes for evaluation and management range from 99201 to 99499. The codes for anesthesia fall into two groups, 00100 to 01999 and 99100 to 99150. Those for radiology range from 70010 to 79999. Category II codes are related to composite measures, patient history, physical exams, screening processes, results, preventative interventions, follow-ups, patient safety, and structural measures. Category III codes are reserved for emerging technologies.

While the CPT code set is required to be used by nearly all insurance (health care) payment systems as well as most medical practice management solutions, it is the copyrighted intellectual property of the American Medical Association, as determined by the case Practice Management versus American Medical Association. Even the Centers for Medicare and Medicaid Services (CMS) requires the use of the codes, as do practical applications of the Health Insurance Portability and Accountability Act (HIPAA). Although the codes appear in the Federal Register, the AMA’s copyright requires that most organizations, practitioners, and facilities that use the code pay fees for licenses required to access it. However, there are limited search capabilities related to the code available on the American Medical Association website. These searches are not intended for use by commercial organizations, only for individual, personal use. CPT Code changes are also announced on the website, in abbreviated form.For up-to-date information on CPT code, you may visit the following website:CPT Code Changes

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OIG "Top Ten" List Costs Hospital Nearly $10 Million : Bridging …

 Nothing strikes fear in the heart of a hospital compliance officer like receiving a medical record request from the Office of Inspector General (OIG). Now, with the OIG’s recent report on its review of Medicare billing by a Midwestern academic medical center, the prospect of such a review is even more terrifying. 

Based on an extrapolation of its findings from a review of 228 claims, the OIG concluded the University of Cincinnati Medical Center (UCMC) owes $9.8 million for overpayments received in 2010 and 2011.

For reasons not explained in the report, the OIG chose to review “Top Ten” claims submitted by UCMC in 2010 and 2011. Through computer matching, data mining, and data analysis techniques, the OIG has identified the following ten types of hospital inpatient and outpatient claims that pose a high risk for noncompliance with Medicare billing requirements: 

1.           Inpatient short stays

2.           Inpatient claims paid in excess of charges

3.           Inpatient claims billed with high-severity-level DRG codes

4.           Inpatient and outpatient manufacturer credits for replaced medical devices

5.           Inpatient transfers

6.           Inpatient psychiatric facility (IPF) emergency department adjustments

7.           Inpatient claims for blood clotting factor drugs

8.           Outpatient claims with payments exceeding $25,000

9.           Outpatient claims billed with evaluation and management (E&M) services

10.       Outpatient claims billed for Doxorubicin Hydrochloride

According to the report, Medicare paid UCMC $256 million for 16,674 inpatient and 98,043 outpatient claims during this two-year period. The OIG’s audit covered $22.8 million in Medicare payments for 2,742 “Top Ten” claims submitted by UCMC in 2010 and 2011.  

Of the total number of “Top Ten” claims, the OIG selected for review a stratified random sample of 228 claims (169 inpatient and 59 outpatient) with payments totaling $3.3 million. The OIG auditors found billing errors on 127 of the 228 claims and calculated the net overpayment as $603,267. Nearly all of the overpayment was attributable to inpatient billing errors; only one-half of 1% related to outpatient billing errors.

With respect to inpatient billing, the vast majority of the overpayment – nearly $400,000 – related to short stays that should have been billed as outpatient rather than inpatient services. The OIG noted that UCMC “may be able to bill Medicare Part B for all services (except for services that specifically require an outpatient status) that would have been reasonable and necessary had the beneficiary been treated as a hospital outpatient rather than admitted as an inpatient.” The OIG, however, did not reduce the total overpayment, noting it would not have enough information to do so unless and until such Part B services are billed by the hospital and adjudicated by the Medicare administrative contractor.  

Two other “Top Ten” errors had significant price tags: claims paid in excess of charges ($153,000) and claims billed with high-severity-level DRGs ($130,000). Other identified errors included manufacturer credits for replaced medical devices, transfers, and psychiatric facility emergency department adjustments.

Without an explanation of how it made the calculation, the OIG extrapolated that UCMC received net overpayments totaling at least $9,818,296 for 2010 and 2011. This represents nearly half of the total amount UCMC received in payment for “Top Ten” claims during the same period.

The OIG expects UCMC to repay this nearly $10 million to the Medicare program. Presumably, the total overpayment will be reduced somewhat once UCMC bills and receives payment for Part B services as explained above, but the amount remains staggering.

According to the OIG, “[t]hese errors occurred primarily because [UCMC] did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.” For the short stays, the OIG identified three specific weaknesses in UCMC’s internal controls: (1) lack of documentation to support the physicians’ clinical decisions to admit patients; (2) physicians’ non-receptiveness to the involvement of case managers; and (3) interpretation of third-party vendor services.

With respect to improper billing for high-severity-level DRG codes, the hospital acknowledged some of these errors were the result of mistakes made by hospital staff. Although mistakes were made on a small number of claims, the alleged lack of adequate oversight had a significant financial impact given extrapolation of the error rate over a larger number of high-dollar claims.    

For UCMC, the OIG’s “Top Ten” list billing errors stands to cost the organization nearly $10 million, an amount hospital officials claim will have a “devastating effect” on its operations. In light of the OIG’s extrapolation of audit results, the importance of proper documentation, coding, and billing procedures cannot be overstated.  

PYA can assist your organization in evaluating and enhancing internal controls and processes around each of the OIG’s “Top Ten” billing errors. Our professionals can assist in resolving internally identified overpayments and provide support in anticipation of and during government audits and investigations. For more information, please contact Nancy McConnell or Denise Hall at PYA, (800) 270-9629.