Observation coding continues to be a vulnerable area when it comes to professional billing and coding. RAC contractors have a keen eye on timing of these services, as the relative value can change significantly based on which services actually are rendered.

Although consolidated payments for the facility portion of SNF care are hot on the RACs’ issue list for 2012, the professional side is also key to beating a Part B audit. In 2011, per HDI, issues for Region D included visits to patients in nursing facilities and visits to patients in swing beds. Payment for Part B SNF care carries a lower RVU value, which, to no one’s surprise, has become a RAC focus being as this area of coding is often misunderstood. Per the fine print provided by HDI, nursing facilities and hospital units providing “swing beds” constitute services often coded as inpatient, thus creating an overpayment for professional services. Another key element to coding these visits properly is reporting the correct POS, which, based on type of facility, also may account for a revenue differential.

Jana presented to over 1000 attendees across the Nation last week at a Wolter's Kluwer MediRegs teleconference educating on Compliance Audits and Evaluation & Management Services.  Wolters Kluwer is offering a Free Trial to the MediRegs Coding Suite and for additional information click here.  The presentation slides are also available. 

As compliance professionals, the conversation about qualifying medical necessity or medical decision-making probably has surfaced at one time or another during education with providers, coders or auditors.  As discussed in the first article of this two-part series, these phrases often are used interchangeably and have caused all of us to think about how to best manage and monitor when it comes to documentation and coding.

The rules of medical necessity and medical decision-making (MDM) are sure to trump the complexity of tax law for the foreseeable future. As the government continues to pump auditing contractors with funds to "fish," the standard algorithm to determine medical necessity has become highly proprietary as providers find themselves under investigation for issues tied to inpatient and outpatient evaluation and management services. As the first of two pieces on this matter, this article will explore the processes of calculating medical necessity, and medical decision-making - and the subjective regulations that factor in.

Gill Compliance is excited to announce the newest member of the team, Nicole Benson.

Gill Compliance Solutions is growing and has brought on an extraordinary new leader to the company, Tresa Brown!  

Physicians are receiving letters citing "Section 1842 (a)(1)(c) of the SSA requiring carriers under contract to the Centers for Medicare & Medicaid Services (CMS) to conduct audits to ensure that Medicare claims are being paid correctly."

As the Centers for Medicare & Medicaid Services (CMS)  announced its record-breaking recovery effort of $4.1 billion for 2011, providers and hospitals were bracing for new depths of audits by government contractors.

The Boise GCS staff takes pride in giving back to local communities.  Jana and Lisa spent time volunteering for the Habitat for Humanity organization painting the interior of a home.  It was so much fun and gratifying knowing your hard work goes to helping others in need.