Reimbursement & regulations: cdm updates, cardiac device credits, and revenue code 456

Though you are hopefully already aware, on April 1, 2018, Medicare updated the Hospital Outpatient Prospective Payment System (OPPS). It is now paying for nonpass-through drugs, biologicals, and therapeutic radiopharmaceuticals that are not acquired through the 340B Program at the average sales price plus 6%. It is important to update your charge description master to make sure your associated charges are correct. Incorrect charges can cause unnecessary reworking of accounts by staff.

To see the new reimbursement rate for these drugs, biologicals, and therapeutic radiopharmaceuticals and to stay abreast of quarterly changes to the average sales price, download Addendums A and B to the OPPS, here. It is also possible to retroactively bill for items that have had their ASP corrected by the CMS. Check this site quarterly for corrected rates. Finally, for a list of pass-through drugs and biologicals, go to Table 5 here.

Revenue Code 456

Having recently completed some research on hospital-based urgent care centers, I thought I’d share some information about Revenue Code 456. When an urgent care center is located next to an emergency department and they share a registration/triage area, staff should be billing the facility charges for services provided with either Revenue Code 456 or 516 depending on location. It is important to make sure staff is avoiding using Revenue Code 450 for general emergency room services when a more specific code is available.

If a commercial payer is stating you may no longer use Revenue Code 456 it is absolutely important to get on the phone with this payer and ask for an explanation of their decision as well as steps for billing in the future. It is also useful to have easy access to all commercial payer manuals to research specific code issues as they arise.

Cardiac Device Credits

Finally, in this month’s spotlight of the OIG I’d like to go over their recent findings regarding hospitals receiving credits from cardiac device manufacturers. After reviewing 296 claims at 210 hospitals, the OIG found that hospitals failed to report credits paid to them for recalled cardiac devices, resulting in $4.4 million in overpayments from Medicare.

The OIG determined that the reviewed hospitals lacked a clear policy for reporting manufacturers’ credits. It is important that once hospital staff inquire as to whether a credit is available they alert billing staff to either hold the claim until the proper payment amount is determined or to make a note to send a corrected claim after the credit is received. Not providing the CMS with the correct information will result in an overpayment, misrepresenting your financial health. Though it may appear that Medicare contractors will not be able to determine if devices have failed or been recalled, audits like this will eventually find overpayments and they will have to be sent back to the government. It is likely that this issue is not confined to cardiac devices and billing staff should go over their policies regarding manufacturer credits to determine that billing is happening appropriately.