CMS recently released its latest Medicare Learning Network (MLN) Medicare Quarterly Provider Compliance Newsletter.  CMS issues the newsletters as educational tools to help providers understand findings identified by the various Medicare claims processing contractors.  Each newsletter describes examples of major billing error patterns that contractors have identified recently and guidance on what steps providers should take to avoid those issues.

In the October 2012 edition of this quarterly publication, CMS provides guidance related to one finding identified by the Comprehensive Error Rate Testing (CERT) review contractor and seven findings identified by Recovery Audit Contractors.  The CERT finding pertained to reviews of power wheelchair claims that have been yielding high improper payment rates due to insufficient medical documentation and medical necessity errors.  The recovery audit findings related to:

  • Major joint replacement or re-attachment and coding issues with respect to major complication or comorbidity (MCC);
  • Medical necessity of acute inpatient admission respiratory conditions;
  • Medical necessity of Other Skin, Subcutaneous Tissue & Breast Procedures (DRG 581);
  • Overpayments of outpatient services billed and reimbursed while the patient was within an inpatient stay paid under the Inpatient Prospective Payment System (IPPS);
  • Place of service coding issues for physician services in an outpatient setting;
  • Coding errors regarding various cardiac procedures; and
  • Coronary bypass with percutaneous transluminal coronary angioplasty (PTCA)/Cardiac Cath with MCC and coding issues.

To review the latest edition of the Medicare Quarterly Provider Compliance Newsletter, please click here.