Updated on: April 2, 2018

When Will Medicare Get Its Priorities Straight?

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Original story posted on: March 26, 2018

Frustrations arise over inconsistent guidance from MACs and CMS.

Every single day, I get numerous email notices from the Centers for Medicare & Medicaid Services (CMS) and the Medicare Administrative Contractor (MAC) for our jurisdiction on a wide variety of “priorities:” correct coding, quality measures, new reporting initiatives, and a never-ending reminder of the myriad things physicians are required to do, document, and report, now and in the future. 

Included in these messages are warnings about progressive corrective action, Comprehensive Error Rate Testing (CERT) findings, incorrect coding and billing, and the need to protect the Medicare trust fund from all the improper claims. 

Wouldn’t it be nice if CMS and the MACs were held to the same high standards of accurate claims adjudication? Wouldn’t it be nice if the same draconian penalties were applied when they made patterns of errors? I think every physician I know would like to know when accountability will be fair and equal to all parties. To this end, let’s take a look at the first two and a half months of 2018.

CMS has created new modifiers to describe the patient-physician relationship: the so-called X modifiers. Although they are slated to be mandatory in the future, in 2018, reporting is voluntary. Presumably, this constitutes important quality information CMS needs, outlining the details of care by different beneficiary providers. 

Our company prepared for this reporting, our physician clients all prepared for this reporting, and on Jan. 1, 2018, we did report to our MAC on every claim. On 100 percent of them, we received a remittance notice that the claims could not be electronically crossed to secondary payers because they could not process the X modifier. 

Hundreds of letters from the MAC stating that fact arrived. And so the due diligence began. Only one secondary payer (Medicaid) was unable to process the X modifiers. All other payers had foreseen the issue, and programming was completed in 2017. Not one of the secondary clearinghouses had any issue. Many hours of research resulted in just one consistent answer: it’s a MAC problem. The end result is an unacceptable amount of lost time, delayed payments, and system reprogramming – all so we could stop the voluntary reporting. I wish that was the target of a CERT audit.

CMS requires provider-based, off-campus facilities to report place of service 19. A new problem reared its ugly head when the new CPT® codes for 2018 were billed in that location. Apparently, the MAC incorrectly programmed, resulting in 100 percent of the radiology interpretations for imaging in place of service 19 being incorrectly denied. Yes, they know and have known since January. An estimated date for the fix is sometime in April. I wonder why delaying legitimate, medically necessary physician reimbursement for four months is acceptable? I wish physicians could correct mistakes when they could work it into their busy schedules, without fear of repercussion.

Not surprisingly, the code updates for National Coverage Determinations (NCDs) again had issues. The October 2017 ICD-10 updates of breast mass codes were finally correctly updated on Jan. 1, 2018 – again, three months after implementation. However, the 2018 new anesthesia codes for upper and lower gastrointestinal endoscopic procedures, including screening for colonoscopy, were not updated correctly for Jan. 1, 2018 dates of service. Perhaps of more concern is that all these incorrectly processed claims were adjudicated as being entirely the patient’s responsibility. As above, a correction is estimated for sometime in April. 

Last on our 2018 list is the fact that the MAC has just notified us that they will reprocess all the new 2018 mammography codes that also were incorrectly denied due to their system update errors.

So, let’s recap. If you are CMS or a MAC, it is perfectly acceptable to make high-volume patterns of errors that incorrectly negatively impact provider payment, without penalty or provider recourse. There is no definitive timeline to correct the revenue disruption the errors caused. We know that in some cases, it took more than a year to resolve. Perhaps if the priority was on getting it right, testing programming, and validating accuracy, less burden would be unfairly placed on providers. 

I wonder what would happen if CMS and its contractors were held to the same level of scrutiny and accuracy providers are? Maybe physicians need the equivalent of CERT: progressive corrective action and integrity auditors to evaluate CMS and MAC performance and initiate penalties for errors. 

I wonder what would happen if the focus was on getting what we have now right, rather than issuing a tsunami of new requirements and initiatives? I wonder what would happen if the focus was really on correctly paying physicians for medically necessary services instead of building confusing, complex payment systems of dubious validity?

CMS, when will you get your priorities straight?


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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Holly Louie, RN, BSN, CHBME

Holly Louie is the compliance officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho. Holly was the 2016 president of the Healthcare Business and Management Association (HBMA) and previously chaired the ICD-10 Committee. Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing, and regulatory compliance. She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and a popular guest on Talk Ten Tuesdays.

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