On November 16, 2015, CMS released a final rule that bundles acute-care payments for knee and hip replacement surgeries, the most common type of inpatient surgeries for Medicare beneficiaries, with some 400,000 performed in 2004.
The Hospital Readmissions Reduction Program is a CMS pay-for-performance program that links the amount hospitals are paid to risk-adjusted readmission rates. Measures included in the program are claims based, which simply means that the ICD-10 codes we submit on our claims for payment are also used to assess our performance; our performance then impacts our payment.
Clinical documentation improvement specialists and case managers share a common goal but often aren't on the same page when it comes to improving documentation within the hospital.
CMS giveth and CMS taketh away. More than $21 billion in payments under the Medicare EHR Incentive Program and more than $10.1 billion in Medicaid EHR Incentive Program payments has been doled out between 2011 and 2015?but not every payment remains with its intended recipient. Contractors will perform audits to ensure that those eligible for the program can support their attestation through examination of supporting documentation to back a claim that a provider or hospital has fulfilled the requirements for meaningful use.
CMS contracted Figliozzi and Company to conduct pre- and postpayment desk audits of the meaningful use program.
"What we have been seeing from our clients' experience is Figliozzi is attempting to perform audits on 5% of attestations submitted to CMS," says David Holtzman, JD, CIPP, vice president of compliance at CynergisTek, Inc., in Austin, Texas.
Holtzman also notes a spike in state Medicaid offices and the Office of Inspector General (OIG) performing audits for those attesting to meaningful use. These audits are conducted on site by a team of auditors.
"Both Medicaid and Medicare meaningful use audits are pass-fail audits," Holtzman says. "Therefore, if any requirement or measure is not met, the result is that the provider or hospital will not receive the incentive payment in the case of a prospective audit or will be required to return any payment received for the prior period as a result of the audit."
Under the Affordable Care Act, the latter would be considered an overpayment by Medicare or Medicaid, and the provider or organization would be required to return the incentive dollars within 60 days or face fines and penalties subject to the False Claims Act.
"There is increased attention by the U.S. Attorney's Office and the Office of Inspector General for investigating and prosecuting fraudulent attestations for meaningful use that results in incentive payments," Holtzman says. "I look at this as a claims recovery effort."
CMS may occasionally report on overall rates of audit failure by eligible providers and hospitals. However, it will not provide any specific guidance on how to resolve identified issues, Holtzman says. "Once the reporting year has ended, the attestation is filed or the hospital/provider selected for audit, no substantive changes are permitted," he says. "Best practices are to carefully review documentation for meaningful use attestation using internal experts or bring in a third-party reviewer to ensure accuracy."
Perhaps recognizing the massive undertaking for coding and HIM departments in 2015 with the implementation of ICD-10, the latest CPT® update includes a relatively small 367 changes for 2016.
Per CPT1, modifier -52 is used when a service or procedure is partially reduced or eliminated at the provider's discretion. Such a situation is identified by using the service's usual HCPCS/CPT code and adding modifier -52, signifying that the service is reduced.
