News to Note – October 2022

• Changes are coming to the 2023 Evaluation and Management codes for patient visits in the hospital setting. We have known about these proposed changes for over a year and they were finalized by the American Medical Association (AMA) who owns the CPT codes in July. Yet, many providers have no idea these changes are coming. Are your doctors’ progress notes loaded with information that’s copied and pasted simply to meet the current coding guidelines? Perhaps your plan is to treat these doctors like children before Christmas, hiding their gifts so they don’t get tempted to start using them before January 1st. More likely than not, they will be positively giddy when they hear they can stop asking about the family history for octogenarians and documenting exam elements that they may have glanced at but didn’t really examine. However, the guidelines for medical decision making will need to be taught to them at some point. 
• Last month, Kepro released their monthly electronic newsletter called Case Connections. In each edition, there is a little blurb from the medical director describing some esoteric initiative by the Centers for Medicare and Medicaid Services (CMS) or Kepro. But, this month they described Kepro’s online appeal tracking tool where you can go online and see exactly where the patient’s appeal is in the process. In instances when the Quality Improvement Organization (QIO) is not so timely with their decision, this is a great way to track it and get written proof if you choose to escalate their poor performance to CMS. 
• Speaking of the QIOs, remember that while we often think about them in relation to discharge appeals, they are also available for patients to call with almost any issue. If the patient does not like the food or their roommate, they can call the QIO. So, if the QIO calls you, it may simply be a fact-finding mission and not an official action. You may want to talk to your staff about how to handle such a call. How do you verify that they really are who they say they are? How much information can you release to them? At what point do you need to involve compliance or risk?
• Last month, the Office of the Inspector General (OIG) released two audit reports: 
• One was an audit looking at care provided in critical access hospitals (CAHs). These hospitals have a different payment structure and one of the ways they differ from other hospitals is that they are permitted to bill for professional services if the provider assigns the rights to the hospital to bill for them. When that happens, the hospital gets paid a higher rate than if the physician billed independently. Well, the OIG audited 20,000 claims for physician services submitted by physicians themselves and then searched the CAH claims for a claim submitted for that same service. Amazingly enough, they found 20,000 matching claims. In other words, CMS paid the physician for their services and then paid the hospital for that same service. If you work at a CAH, alert your staff to this and tell your doctors to stop sending in bills when they agreed not to do it. 
• The second audit looked at outpatient billing for services provided to patients who were admitted as an inpatient at another facility. Remember, when a patient is an inpatient and needs a service that cannot be provided at that facility, the patient may be sent to another facility for the procedure and then return to the original facility. But, the cost of the service is the responsibility of the original inpatient hospital and the facility that does the procedure should not be billing Medicare. Well, as in previous audits, this continues to happen, this time at a cost to the Trust Fund of $39 million per the OIG. But, that’s not necessarily correct because if the hospital that billed the admission had included the service on their claim, that service may have changed the DRG or resulted in additional payment to the hospital. But it is still a common error that should not be happening. Under arrangement billing rules are well known but the problem is that the billing staff never finds out that the patient went somewhere else for a test or procedure so the claims get messed up. If you are sending an inpatient out for a service, be sure everyone knows. 
• It is clear that the problem of custodial patients occupying hospital beds is a growing problem nationwide. Remember, once the necessary care is done, you should stop billing observation hours and start billing custodial care hours with code A9270. Quantify the amount of free care you are providing and then maybe you can get the resources to start addressing it.