When Will Medicare Get Its Priorities Straight?

By 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?

False and Nonsensical Medical Records Reportedly Not Unusual

Poorly designed EHRs likely the culprit for the proliferation of false medical records.

Last week Talk Ten Tuesdays listener “Robert” discussed during the weekly Internet broadcast the fact that a physical examination documented in his medical record for a recent hospital visit was false, indicating that the physician never performed an exam.

Sadly, this is not a startling revelation or a unique occurrence.

Coders and auditors see false or nonsense documentation every single day. The difference in Robert’s story is that he is knowledgeable in coding and billing and had the expertise to evaluate the documentation. Most patients never see their medical record, and thus it is highly likely that innumerable cases of false documentation go undetected. More importantly, unless there is a noticeable error or other warning flag, coders and auditors may have no way to see below the tip of the iceberg.

This proliferation of false documentation is largely attributable to poorly designed electronic health records and similar templated documentation systems. The need for providers to document extensive notes to incorporate all the “quality” information and other payment methodology requirements has resulted in what is not-very-fondly referred to as “note bloat.” When we add in the Centers for Medicare & Medicaid Services (CMS) and CPT® Evaluation and Management (E/M) service documentation requirements, there is a lot of required information that may or may not be relevant to support a specific level of service.

The fact is that documentation takes an ever-increasing amount of time physicians often do not have. This results in attempts to streamline the process, and those solutions have the potential to create the exact opposite of the desired outcome. A very popular solution is the one-click methodology that creates a standard, pre-filled document. The thought is that the provider will edit and correct that standard to accurately reflect actual patient encounters. Unfortunately, but not surprisingly, that often does not happen.

As a result, we see patients suddenly re-growing limbs or anatomical parts they don’t have, a “normal” exam of a noticeable injury, no exam of the chief complaint, etc. In some cases, faulty editing makes a bad situation worse. For example, I just read a medical record for which the patient’s head exam included bowel tones. In many cases, the physical exam is in direct contradiction with the rest of the encounter documentation. Those are the obvious errors that are easily identified.

In Robert’s case, without a patient complaint, it is probable that the false documentation would not have been identified. However, at least Robert was really there that day. Cases of complete notes being produced when no patient visit occurred are also not uncommon. The practice of pre-populating the scheduled patient visits to edit later has also gained traction. If due diligence is not vigorously exercised, those completely false notes are billed.

A reasonable recommendation for Robert’s case was to contact the provider and/or compliance officer. Sadly, we have seen cases in which even that is ignored, and no corrections to the false records were made. In some cases, even the payer fraud units failed to respond, choosing to believe the medical record over the patient.

We know that the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) and CMS have been focused on these issues for quite some time. Interestingly, CMS in the proposed physician fee schedule requested input on revamping E/M documentation requirements, including the possibility of eliminating them.

The fact is that false documentation has the potential to cause great patient harm. More is not necessarily better. Documentation really should be customized, accurate, and useful for clinical care.

Until the focus is on what really matters, we have a huge problem requiring a solution.

Program Note: For more information on this subject listen to Holly Louie today on Talk Ten Tuesdays at 10 a.m. ET. Register to listen.

Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.

CMS Shares Thoughts Behind the MACRA Proposed Rule MIPS Changes

The Healthcare Business Management Association (HBMA) Government Relations Committee was fortunate to again have the opportunity to meet with CMS directors, deputy directors and Senate Ways and Means Staff the day the proposed rule was published.  As I think we all have recognized, the most significant changes were intended to help small providers and practices.  The proposed threshold increases in patient volume or dollars have in effect exempted many providers from MIPS participation.  The ability to form virtual groups is also intended to allow maximum flexibility.  Those are positive steps in recognition of the challenges MIPS presents.

In addition, many new options are proposed.  For example, the ability to report 2018 quality measures via multiple methods as opposed to only claims, registry, etc.  More measures have been added to increase successful reporting choices and opportunities for participating providers.

While these increased options and choices may sound good at first blush, the fact is that complexity and therefore cost for providers also increases.  The thoughts and work behind the changes are well intentioned.  However, “One man’s idea of perfect order is another man’s chaos.”  Dean Koontz

Some of the most basic informed decisions providers must make are whether they want to work toward a bonus, remain revenue neutral, or accept a penalty.  Accurately performing those projections based on specialty and practice specific variables requires increasingly sophisticated software support and data analytics.  The unfortunate fact is providers can make best efforts to do everything right and still not be guaranteed of a bonus or even the amount of the bonus.  Because the program must be revenue neutral, for every winner there must be a loser.  One observation is the fact that, “most providers will be forced to the middle”.  And that is the crux of the problem with MIPS, in my opinion.  How much money and work will providers invest when there is no return on that investment?  We already know a very large percentage of eligible providers never participated in PQRS.  Are we really going to accept that none of those physicians or practices is providing quality care?  Are we really going to accept that every physician or practice that does participate is providing the best quality care?  I hope not, for that is a false belief that reporting data is the same as providing quality care.

The CMS intent is noble, to ensure all beneficiaries receive high quality care at a reasonable cost.  The methodology to achieve that is flawed.  Adding myriad options that simply increase cost and complexity for physicians and their representatives, with no return on those investments, continues to whittle away at the precious time physicians have for their real job-patient care.  That’s where quality happens, not in data reporting.  Let’s help physicians get back to what they do best by removing the overwhelming administrative burdens.  Then we will see real and meaningful quality.

Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and was the 2016 HBMA president.

Growing Insurance Denials Creating Undue Physician Hardship

Growing Insurance Denials Creating Undue Physician Hardship

By Holly Louie, RN, CHBME

Much attention and dedicated work have been devoted toward clinical documentation improvement and accurate, specific coding. Clearly, those are of great importance. However, I want to address the physician Part B insurance denials that have nothing to do with how good the clinical documentation is and how accurate the coding is on the claims. Common frustrations that we see every day are myriad.

Consider requests for prepayment review for a service with an allowable billing of $8.90. It will cost two or three times that much to gather reports, orders, and supporting medical records. Is that really a reasonable use of anyone’s time?

Incorrect or delayed payor updates and edits as new codes are released and new policies are published can cause claim denials for months. In a few cases, the payor will reprocess the incorrectly denied claims. However, in many cases, it is up to the provider to monitor and resubmit the claims to obtain legitimate payment, incorrectly denied.

Radiologists are held accountable for what the referring providers document to support the medical necessity of the diagnostic testing they order. Not only is it a tremendous burden to have to obtain that documentation, but if the referring physician documented poorly, it is the radiologist’s payment that is recouped.

Some of the Centers for Medicare & Medicaid Services (CMS) medically unlikely edits (MUE) for a date of service are not consistent with standards of practice for some specialty services. Rather than paying at least the number allowed per day and requiring appeals for any services exceeding the total allowed, all units of service are denied. Yet, again, appeals are required, which greatly increases work and cost for the provider (and presumably for the MAC, or Medicare Administrative Contractor).

Entities that pre-authorize services may not have correct payor information. For example, a common problem is authorization of a specific CPT. However, the payor may actually require a HCPCS code for the service. The authorized service is denied, and when the claim is corrected to meet the payor coding requirement, it is denied again as being unauthorized. It’s a vicious circle that withholds legitimate payment for legitimate services.

More and more payors are not accepting calls from revenue cycle companies or physician billing representatives. Not all issues can be successfully resolved via email, so a large roadblock can exist. When calls are accepted, our experience is that the average hold time is 20 minutes. In addition, many insurance companies limit the number of questions that can be asked on a call. This issue is greatly exacerbated by the large volume of remittance explanations (CARC/RARC) that are so nebulous or completely inaccurate that the reason for the denial cannot be ascertained. The time and cost to even attempt to get an answer is frankly, absurd.

I think the physician community and the billing industry as a whole would like to see insurance companies held to the same rigorous mandates for transparency, accuracy, timeliness, and accountability as the rest of us.


Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and was the 2016 HBMA president.

Dear Doctor, Tell Me What You Really Think


Every two years one of the most interesting perspectives on medicine in America is published by the Physicians Foundation.  www.physiciansfoundation.org/…/Biennial_Physician_Survey_2016.pdf

In the 2016 survey, 17,236 physicians responded to a wide variety of questions about their practice, the state of the healthcare industry, and perspectives on specific topics, including ICD-10.  Although ICD-10 was still relatively new in 2016, the responses raise a red flag.  Not that ICD-10 is a problem in and of itself, but that it is one more issue physicians have identified as problematic in the big picture.  For some issues, the same or similar findings have now been published for six years, with some minor fluctuations, but appear to have fallen on deaf ears.  These very same issues have been raised by numerous other industry stakeholders.  These issues are the ones that scream administrative simplification is an oxymoron, that many EHRs are a barrier to quality care and the physician patient relationship, that far too much time is spent on red tape and non-clinical work, that the administrative burdens are overwhelming, that morale is low for many, and that both the patients and physicians have been lost in quest for “quality”.

While each of the issues could be addressed individually, I believe we need to start with the big picture.  ICD-10 is just one small piece of the quality picture.  There are the mandates enacted through the Affordable Care Act (ACA), the Medicare Access and CHIPS Reauthorization Act (MACRA), the Merit Based Incentive Payment System (MIPS), the electronic health records (EHR) incentive program, etc.  When you add all of the other regulatory and clinical practice requirements physicians must meet, it is quite easy to see how quickly one can be completely overwhelmed.  Unfortunately, each of these regulations seems to increase exponentially in complexity and difficulty.  The rush to implementation has taken precedence over getting it right.

One thing EHRs were supposed to do was to greatly improve clinical documentation accuracy and thoroughness.  As a result, diagnostic coding would be more specific, more accurate and better communicate patient care and outcomes.  This would not only result in higher quality care but also in better data for analysis and more appropriate reimbursement.  However, the physician survey results found only 29% of physicians believe EHRs improved quality of care, 25% believe it increased efficiency, and a disheartening 11% believe patient interaction was improved.  60% of responding physicians reported EHR has detracted from patient interaction.

Specific to ICD-10, the survey results also reflect a failure to meet the well intentioned goals.  Only 6% of physicians see improved efficiency, 6% saw any increased revenue and even more disappointing, only 5% believe patient care has improved.  Although 52% of responses said they saw no impact from ICD-10 implementation, 42.5% said it detracted from their efficiency.

It seems plausible that quality has gotten lost in regulatory requirements that impose additional time and non-clinical work burdens.  Based on the survey, 21% of a physician’s time is spent on non-clinical work such as pre-authorizations necessary to meet payor reimbursement demands.  Aggregated, that lost clinical time is estimated to be equal to 168,000 physicians!  It also seems plausible that when physicians consistently report they are over extended, the time they do have is prioritized on their patient interactions and care, not becoming experts in all the regulatory demands and “quality” expectations.  If EHRs are not efficient, clinical documentation improvement will fall victim to those inefficiencies.  If clinical documentation improvement does not occur, the ICD-10 goals will also not meet the expected results.

Quality care, in the opinion of many physicians, has a much better chance of being realized when how, what, when and why are not based on regulatory and idiosyncratic payor requirements.  Will every physician agree with the findings?  Of course not.  But there is a strong message from more than 17,000 physicians that we should heed.

“The happiness of too many days is often destroyed by trying to accomplish too much in one day.  We would do well to follow a common rule for our daily lives – DO LESS, AND DO IT BETTER.”  Dale E. Turner


Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.


The Cures Act did not Cure the Local Coverage Decision Issues

The Cures Act (https://www.congress.gov/bill/114th-congress/house-bill/6t ) does many things for improving biomedical research and advancing clinical trials.  Subtitle E – Local Coverage Decision Reforms addresses the requirements for local coverage decisions (LCD).  This section specifies the required documentation to support coverage policies and that the policy must be posted on the CMS website 45 days before implementation.  Unfortunately, that is a distinction without a difference, in my opinion.  In reviewing multiple Medicare Contractor (MAC) websites, the almost verbatim requirements are already required and stated.

So what would a meaningful LCD cure look like?  The Healthcare Business Management Association (HBMA) believes LCDs are long past any relevant and useful purpose.  In fact, the organization advocates for LCD elimination.  How can you have valid quality or care comparison metrics when what is medically necessary in one jurisdiction is not medically necessary in another?  Once a national coverage determination (NCD) has been made, it should suffice for the nation.  Multiple interpretations of what that means are not necessary.  Diagnoses that support medical necessity could easily be incorporated into the final determination and thus remove all ambiguity and idiosyncratic interpretations.  In addition, in some cases, the MAC will not respond to LCD reconsideration requests because they must wait for clarification from CMS on the policy.  As a result, from October 1, 2016 until an estimated date of January 1, 2017, providers in one jurisdiction do not know if some services will or will not be covered.  They know it was covered on September 30.  There is just no information about why it was not covered on October 1 and no reconsideration will be addressed.

I strongly believe this type of confusion and unclear local coverage creates great angst among beneficiaries and their providers.  It is very difficult to explain why the test or service was covered at the time it was ordered but is not covered, or coverage is unknown, by the time service is provided; even if it is one day later.  Is it even possible to issue a valid advance beneficiary notice with the reason for expected non-coverage stated as, “No one has any earthly idea what Medicare will decide”?

The very LCD process is fraught with errors.  As we have discussed in previous articles and presentations, we have seen numerous examples of 2015 ICD-10 conversion errors and 2016 update errors and omissions.  Sadly, it appears the procedure and incredible onus to have these errors corrected falls on the providers.  In addition, when errors are made in an NCD they permeate the entire program and even trickle down to some commercial payors and Medicaid plans.  Although MACs have the ability to interpret correct national policies, it seems they are not permitted to have an LCD interpretation that overrides obvious and admitted errors in national coverage policies.  A real cure would be an expedited process to correct errors promptly in national coverage policies, rather than waiting many months for rectifying mistakes and even longer for them to be implemented locally.

The Cures Act did not cure local coverage decisions.  Perhaps because they cannot be cured.  They are the equivalent of the most virulent antibiotic resistant organisms.  Let’s hope it does not worsen with the implementation of all the new procedure codes and MIPS on January 1.  Let’s really address the cure and eradicate local coverage determinations.


Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.

It’s Déjà Vu All Over Again

With more than a full year under ICD-10, it seems it is reasonable to expect local coverage determinations (LCD) to be current and correct.  After all, everyone in the industry knew there were errors and omissions in some national and local policies.  Many had already been pointed out.  And yes, some have been corrected.  The expectation was that contractors and commercial payors would take the initiative to review all their publications and make necessary corrections.  Not only has that not been done universally, but it appears more errors have arisen in the October 2016 updates.

It also appears the onus is on providers and their representatives to find the errors, notify the contractor of the problem through a formal LCD reconsideration process, and wait for a response to the request to learn whether corrections will be made and if they will be retroactive.  In fact, one contractor explicitly stated they would not review their policies unless an error was pointed out through the reconsideration process.

Just a few examples of LCD issues include: coverage for the initial and subsequent encounters but no sequela codes, the entire category of collapsed thoracic vertebra was omitted, no pregnancy related respiratory diagnoses, the entire category of displacement of bone devices, implants and grafts was omitted, cardiac pacemaker covered services omit certain parts of the pacemaker, October 2016 codes with expanded descriptions were completely deleted when the “parent” code was no longer valid, and the list goes on.

In reality, providers and their representatives may not immediately identify key omissions or errors for myriad reasons.  They may provide a new service or see a new and different patient population, a third party revenue cycle management company may begin coding and billing for a new client specialty, the specific disease, disorder, sign or symptoms may not have been documented in past cases, the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 have added or modified coding instructions, clinical documentation improvement changes historical coding, etc.

Based on some industry reports over the last year, these issues raise the concerns of reporting accuracy.  Will less or inaccurate codes be designated when the correct codes are not covered due to policy diagnoses errors and omissions?

While providers certainly must take responsibility for evaluating coding related issues and denials and address them as necessary, the contractors and commercial payors also have an obligation to accurately update and monitor their policies for errors, oversights, mistakes and omissions.  For the contractors and payors to place the onus on the providers not only to find the issues, but to request reconsideration seems to be shifting what is a clear responsibility to someone else.

It is disconcerting that providers are expected to know and comply with every law, rule, policy and guideline or risk what are potentially very punitive results, but the same high standard does not appear to be required of the contractors and payors.

With rare exception, providers are doing their best to provide quality, cost effective patient care while being inundated in operational and regulatory requirements.  Asking them to perform free quality assurance for contractors and payors is unreasonable.  Let’s place the accountability and responsibility where it really belongs.


Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.

Good News, Bad News The Saga Continues

The long awaited update to the CT lung screening NCD was finally released this July.  As you may recall, current smokers who were otherwise eligible were omitted from the NCD covered codes released last year.  That is the really good news.  The really bad news is at least one MAC denied all of the claims submitted for DOS 2/5/15 through current.  The reason seems to be that their system was programmed to require both the diagnosis for a past history of smoking, as well as the diagnosis for a patient who  currently smokes on the same claim for service.  Per the ICD-10 authoritative coding conventions, “Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring”.

Not only is this unexpected surprise incredibly frustrating, it is an inordinate amount of work and expense unnecessarily put on providers and their billing companies.  Either every claim must be recoded manually or software must be programmed to automate the process.  For those fortunate enough to have proprietary software and in-house programmers, it is still work but likely more feasible.  In dealing with software vendors, few, if any, are willing to program for “one offs” and significant time may be required.  So, the bottom line is that payments are still withheld until providers do the work to overcome the edit.  And 17 months of unpaid claims is not a small matter.  How this will trickle down to Part C and commercial payors is as yet unknown.  The issue and request for clarification has been brought to the attention of CMS and Dr. Bill Rogers, the ICD-10 ombudsman.  Hopefully, a quick resolution for providers will be the outcome.

This is just one example of the never ending problems with local coverage determinations.  Many still have glaring omissions from the conversions to ICD-10 last year.  For example, no subsequent treatment code choices for intracranial hemorrhages.  In another case, although the LCD states only chronic conditions for a certain procedure are covered, the LCD includes only acute codes.  Conversations with the MAC and the regional offices confirm a formal process is required to have updates to these oversights and omissions.  Simply pointing them out will not suffice.  In fact, one MAC requested a review and listing of every identified issue for each LCD.  My question is why didn’t you do that before it was published?  The industry has been told many times that all NCD and LCD policies are thoroughly reviewed by coding experts prior to publication.  I beg to differ.  Res ipsa loquitor.

At a recent meeting with CMS, HBMA strongly advocated for the end of LCDs.  An enormous amount of time is wasted each and every year by both the MACs and providers in wrestling with inconsistent and/or incorrect interpretations.  This was greatly compounded with the implementation of ICD-10.  When the old LMRPs were retired and LCDs introduced, the major benefit was to be consistency among policies.  That has not even come close to fruition.  HBMA believes this is counterintuitive to the goals of Administrative Simplification.  The good news is that CMS did listen thoughtfully and carefully to the position.  Time will tell if it will result in improvements.

With such a large number of new codes coming this October, more issues seem highly likely.  Close monitoring and review is recommended.  The sooner omissions and errors are brought to the MACs attention, the sooner correct payments will ensue.

As part of their gracious allotment of time and attention, CMS also reminded HBMA attendees that the so called grace period of audit specificity is ending October 1, 2016.  This has been an oft misunderstood and misstated policy.  The requirement for accurate and specific coding is the same as it has always been.  The grace period was for auditing, not coding, and was to allow less than the most specific codes within a family to be accepted, with certain exceptions such as laterality.  Given recent publications outlining significant errors on documentation and coding audits, this should be a very high priority for providers, EHR and coding software vendors.

In closing, the good news is CMS is aware of some of our providers’ most difficult MAC issues and willing to address them.  The bad news is we are still stuck with MAC policies that are inconsistent and not provider friendly.

Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.

Dear Doctor, We Don’t Care If You Don’t Get Paid Promptly

By Holly Louie, RN, CHBME

The story that I am going to relate could borrow a line from the movie When Harry Met Sally.  Sally is sobbing and says she is going to be 4o.  When Harry asks when, Sally responds, “Some day!”  And that is our punch line to this story.

There has been so much talk about how smoothly ICD-10 has gone.  No big surprises, no significant increase in claims denials, cash flow not significantly disrupted.  But wait!  Let’s talk about the forthcoming CMS announcement about just one National Coverage Decision absolute disaster.  This is not an isolated problem, but the best example I know of how bad it can get, how quickly it can snowball and how long providers are expected to just wait for payments.

On February 5, 2015, CMS issued a National Coverage Determination (NCD) for screening for lung cancer with low dose computed tomography (LDCT).  There is no doubt this was a very good decision.  However, at that time, CMS did not provide any instructions regarding CPT, HCPCS or diagnosis codes that would be covered under this policy, or any methodology to bill for the services. That would be released, “some day”.  In spite of pressure from numerous organizations, the HCPCS code was not released until the 2016 fee schedule was published in the final quarter of 2015.  The date providers could begin billing the code was January 1, 2016.  It was bad enough to wait almost a full year to bill for all the legitimate, medically necessary services provided to Medicare beneficiaries, but the other shoe was about to drop.

For those not in the radiology space, the policy covers people who smoked in the past or who are current smokers, as long as other specified criteria are met.  When the covered diagnosis codes in ICD-9 and ICD-10 were published in October, it was immediately obvious that CMS had completely omitted the diagnosis codes for current smokers.  (See MM9246)  In spite of the fact that this error was brought to the attention of CMS, and they agreed there was a significant omission, they responded that it would be addressed at their earliest convenience.  This omission was incorporated in the applicable Medicare manuals, NCD and other transmittals and instructions.

Communications with CMS over the past week have resulted in the promise of a forthcoming transmittal that will explain how and when corrections will be made.  Because NCDs are only updated quarterly and because CMS was already working on the quarterly updates well into 2016, the earliest we can expect corrections for claims is in the July 2016 publication, possibly to be implemented in October.  Ladies and Gentlemen, that is 1 full year plus either 5 or 8 months before any correct adjudication will begin.  Will claims need to be resubmitted or will they be reprocessed?  There will need to be overrides for timely filing and other operational realities.  Will the providers also have to bear that burden?

No one expected CMS to implement the myriad changes required by ICD-10 error free.  Mistakes happen.  But this system is broken and it needs to be fixed.  Once a coverage decision has been made, the mechanism for submitting claims and receiving correct payment should be in place before issuing notices.  Holding claims for 11 months is not ok.  Correction of egregious, or even minor errors, should certainly not take 6 months or longer.  Prompt interim instructions should be implemented to allow claims submission and correct adjudication and payment as soon as the error is known.

It seems to me we have a double standard.  When a Medicare contractor wants something there is a very short time line to respond or suffer the consequences.  When CMS has errors, there is apparently no clock for resolution or concern for the providers who cannot get paid for treating Medicare beneficiaries.  In this case, we can expect payment, “some day.”

Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.