Submitting error-free claims.

Marc Zimmet is senior reimbursement consultant and Sheryl B. Rosenfield is director of clinical services for Zinunet-Hecht Associates, a consulting firm with offices in New York City and Old Bridge, New Jersey.

An internal audit can root out violations of Medicare policy

NOW THAT THE PROSPECTIVE PAYMENT SYSTEM IS WELL underway, it's time to examine your internal procedures to ensure that you are operating within regulatory guidelines. Medicare thinks so, too. The PPS final rule explains that HCFA is formalizing its medical review criteria and stepping up its efforts to "strengthen program integrity [and] deter fraud and abuse."

Claim submission involves significant input from several departments. Nursing must complete and validate the minimum data sets, therapy must provide service as appropriate, and both departments must properly document their work to support the need for skilled care. The biller must then decipher pertinent data and enter it onto the UB-92, translating the "reason for assessment" (MDS section AA8a,b) into one of 19 allowable modifier codes and assigning the correct number of covered days to each MDS applicable to a calendar month.

Due to the involvement of many so many professionals, the complexity of the PPS guidelines, and the limited time to perform each task, many claims contain some inadvertent violation of Medicare policy. These violations fall into three categories: technical errors, process errors, and documentation errors.

* Technical errors pertain to mistakes on the UB-92, such as inaccurate service dates (assessment reference dates), miscoded modifiers, or ancillary charge omissions. A common error is incorrect assignment of covered days to a specific assessment. During any given month, a resident may have multiple MDS forms dictating payment at differing rates. Inaccurate assignment of days billed for each assessment compromises the integrity of the claim.

For instance, a resident admitted October 1 is scored RHC on the 5-day assessment (which covers the first 14 days of a stay), RMC on the 14-day (which covers the next 16 days), and CC1 on the 30-day (covering days 31-60). The October claim should charge Medicare for 14 days at RHC, 16 days at the lower paying RMC, and 1 day at CC1 (the remaining 29 days carry over to the November bill). If the U13-92 inadvertently reports 14 days at RHC but 17 days at RMC, the facility has over-billed Medicare for one day of care.

This error is common on more complicated claims involving Other Medicare Required Assessments (OMRAs) and Significant Change in Status Assessments (SCSAs) that replace on-cycle assessments.

Billing software that is linked to MDS software and automatically records days charged per assessment frequently assigns covered days inaccurately. If your software automatically assigns cover days, make sure someone double-checks all claims and manually overrides any errors.

* Process errors involve failure to adhere to Medicare assessment guidelines and breakdowns in organizational procedures. Common process errors include incorrectly inputting the handwritten MDS into the computer; unlocking the MDS; referencing, signing, or locking the MDS in an untimely fashion; and missing an OMRA or SCSA.

Operational breakdowns are the most common process error. For example, the MDS is locked and printed out when a nurse realizes the document contains an error (e.g., the reference date should be October 5 instead of October 7). The nurse crosses out the error and writes in the correct information. Billing then calls up that MDS on its system to complete field 45 of the UB-92, unaware that the nurse has changed the data. The result is inconsistency between the bill and the MDS.

Data entry errors are also a major problem and typically occur when there is no system of checks and balances in place. In one of our audits, we uncovered in Section P of the MDS that a resident received 245 minutes of PT over the past 7 days. The clerk had erroneously input 2450 minutes of therapy. The patient was scored in the ultra high rehab category instead of the high group, and Medicare was overbilled. This error occurred because no one was assigned to review the clerk's work.

* Documentation errors occur when supporting nursing or therapy notes do not agree with the MDS. The MDS is a snapshot of information collected at a point in time. Clinicians must ensure that their notes are reflective of the residents' condition as of the MDS reference date. Common errors include non-descriptive progress notes, service omissions, incorrect scoring of activities of daily living, and inconsistencies between the MDS and clinical notes. For instance, "Rehab Potential" is left blank on the MDS for a resident who is on restorative therapy.

Your challenge is to monitor activities and ensure that your facility is operating within program guidelines. Understanding the common errors types should help you identify the weaknesses of your procedures, take corrective actions, and maintain the integrity of the Medicare program.