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Medical Coding News Archives

OIG Spots Errors Coding Mechanical Ventilation and RHC with Biopsy

September 26, 2017:

Right heart catheterizations (RHC) with heart biopsies and 96 or more continuous hours of mechanical ventilation are posing particular challenges to coders, according to two recent reports from the Office of Inspector General (OIG).

RHC and heart biopsy: In a March 2017 report, OIG noted that most of the hospitals it had reviewed failed to comply with Medicare billing requirements for outpatient right heart catheterizations performed at the same patient encounter as heart biopsies for the years 2011 and 2012. The agency estimated that the errors cost Medicare $7.6 million in overpayment over two years. Some hospitals erroneously appended modifier 59 to the HCPCS code to indicate that the procedures were separate and distinct. Payment for a heart biopsy generally covers an RHC when both are performed at the same encounter.

The National Correct Coding Initiative (NCCI) includes procedure-to-procedure edits that identify code pairs that should not be reported together for the same beneficiary and same dates of service. If each of the procedures is performed separately, modifier 59 may be appended to bypass the edit. In the case of heart biopsy and RHC, both are routinely performed together after heart transplantation to monitor heart function and the surgery’s success. When the RHC is performed to obtain a heart biopsy, the two procedures are not considered separate and distinct and modifier 59 cannot be used.

The OIG found that for every 100 sampled line items for RHC it examined from 140 hospitals, 92 line items did not comply with Medicare requirements. It seems that some hospitals listed modifier 59 when the RHC was used to do more than take a heart biopsy. For instance, the RHC might have been used also to measure hemodynamic pressures.

The Centers for Medicare and Medicaid Services (CMS) has agreed to educate providers on the correct way to bill for RHCs and heart biopsies performed on the same date for the same beneficiary. It also plans to look at claims from years later than 2012 to identify this error and recover overpayments.

Mechanical ventilation: OIG also found significant errors in how facilities reported the number of hours of ventilation provided to inpatients whose cases fell into Medicare severity diagnosis-related groups (MS-DRG) 207 (Respiratory system diagnosis with ventilator support 96+ hours) and 870 (Septicemia or severe sepsis with mechanical ventilation 96+ hours). Out of 200 claims reviewed from between 2012 and 2014, 63 did not meet the threshold for 96 consecutive hours of mechanical ventilation as specified in these MS-DRGs. The hospitals at fault readily admitted their mistakes, blaming miscalculations of ventilation hours or clerical errors.

OIG found that shortcomings in the length of stay edit have allowed this error to go undetected. Rather than identifying claims with potential procedure length of four days or less, the edit focused on lengths of hospital stay of four days or less as measured by the date of admission. Had the edit picked up on the dates mechanical ventilation began and ended, more claims with potential errors would have surfaced. For stays of more than four days, some hospitals were measuring the length of ventilation by the dates rather than the times ventilation began and ended. For example, a patient who began ventilation at 2:30 pm on day one of his stay and went off ventilation at 9:30 on day five received only 91 hours of ventilation. Reporting this case using ICD-10-PCS code 5A1955Z (Respiratory Ventilation, Greater than 96 Consecutive Hours) (ICD-9-CM code 96.72) rather than 5A1935Z or 5A1945Z groups it to the higher-paying MS-DRG 207 rather than the correct MS-DRG 208 (Respirator system diagnosis [with] ventilator support less than 96 hours).

This incorrect assignment of cases with fewer than 96 hours of ventilation to MS-DRGs 870 and 207 accounted for a total of $19.8 million in Medicare overpayments over the course of two years, OIG estimates. Among OIG’s recommendations to CMS is its proposal to change the length-of-stay edit to take into account the procedure length as measured by the start and end dates of mechanical ventilation.

In response to OIG’s recommendations, CMS instituted an edit whereby, effective October 1, 2012, claims submitted with ICD-9-CM procedure code 96.72 or ICD-10-PCS code 5A1955Z with a length of stay of fewer than four days are returned to the provider for validation and resubmission. The agency also implemented an edit effective October 1, 2016, that ensures that the mechanical ventilation procedure start date is used to calculate consecutive days.


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