Billing and reimbursement

One of the most memorable sessions at the AMA CPT Symposium in November 2017 involved an impromptu open mic feedback session facilitated by CMS’ Marge Watchorn, deputy director of the Division of Practitioner Services. The focus of this session was the applicability of the current CMS documentation guidelines for E/M services.

What laboratory services are covered under the rural health clinic benefit?

Incorrect inpatient rehabilitation facility (IRF) claims led to $444,458 in overpayments at Memorial University Medical Center, a Savannah, Georgia-based hospital, according to a recent Office of Inspector General audit report. IRF billing compliance has been on the OIG’s radar for several years, and Medicare Administrative Contractors and supplemental medical review contractors have been placing these claims under increased scrutiny.

In the current healthcare climate, the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. For a service to be considered medically necessary (by a third-party payer), it must be considered a reasonable and necessary service to diagnose and/or treat a patient’s current and/or chronic medical condition.

Coding and documentation can make or break providers’ success under the Quality Payment Program. An examination of specific measures reveals coding and documentation areas to focus on.

What requirements must a facility meet to be considered a rural health clinic?

An audit of Medicare Part B payments from 2014 through 2016 revealed that CMS improperly paid providers more than $66.3 million for specimen validity tests billed in combination with urine drug tests, according to a report by the OIG.

How should rural health clinics bill for an EKG performed at the time of an initial preventive physical exam?

Electronic health records fall short of early promises that they would reduce administrative costs, a recent study found. The cost of completing insurance- and billing-related activities in the EHR can represent more than a quarter of professional reimbursement for an emergency department visit.

The expected growth in healthcare expenditures from 2017 to 2026 is expected to outpace the growth in gross domestic product (GDP) by 1%, resulting in an increase in the health share of the GDP from 17.9% in 2016 to 19.7% in 2026, according to a CMS report.