CMS released the inaugural edition of a new educational tool, the Medicare Quarterly Provider Compliance Newsletter (Newsletter) on October 5, 2010. The Newsletter is intended to provide physicians, providers and suppliers advice on how to identify and prevent common Medicare billing errors and other compliance issues. Many of the issues discussed were discovered due to reviews by the General Accountability Office, the OIG or other CMS contractors, including Recovery Audit Contractors (RACs), Program Safeguard Contractors, Zone Program Integrity Contractors and Medicare Administrative Contractors.

The first edition highlights eight issues and begins with concerns that inpatient hospitals and skilled nursing facilities are failing to deliver requested documentation to RACs, CMS or other contractors in a timely manner. The agency warns that insufficient documentation may be considered an overpayment, and incomplete or illegible medical records can result in payment denials. The Newsletter recommends that providers implement a plan of action and a point of contact responsible for tracking and responding to RAC ADR letters.

The Newsletter also addresses the concern that medical records did not include adequate documentation of inpatient hospital services. CMS notes that the reviews by Demonstration RACs resulted in $63 million dollars identified as overpaid due to insufficient documentation.

Other issues discussed in the Newsletter include:

  • Submission of claims in which the units billed exceed the number of units approved under CPT descriptions.
  • Principal diagnoses on claims not matching the principal diagnosis in the medical record for respiratory system diagnosis with ventilator support.
  • Medically unnecessary inpatient care for "Other Cardiac Pacemaker Implantation (DRG 116)."
  • Claims for heart failure and shock (DRG 127) that do not meet inpatient care criteria.
  • Excessive or multiple units billed for drug codes.
  • Incorrect coding of pharmaceutical injectables, including duplicate claims, excessive/multiple units and medically unnecessary administration of Neulasta.