Staying ahead of Medicare compliance changes can help healthcare organizations reduce audit risk, improve billing accuracy, and identify potential reimbursement issues before they become larger concerns. Two recent CMS updates highlight areas providers and facilities should review closely.
Dermatology Billing: E/M Services and Minor Surgical Procedures
CMS is reminding dermatologists and billing staff to ensure Evaluation and Management (E/M) services are billed correctly when performed on the same day as a minor surgical procedure.
A recent review by the Office of Inspector General found that a significant percentage of Medicare dermatology claims included both an E/M service and a minor procedure on the same date of service. Under Medicare’s global surgery rules, routine E/M services associated with a minor procedure are generally included in the procedure payment and should not be billed separately unless specific requirements are met.
Providers should pay particular attention to:
- Appropriate use of Modifier 25 when a significant, separately identifiable E/M service is performed.
- Documentation requirements that support the level of service reported.
- Compliance with Medicare global surgery billing guidelines.
Organizations that provide dermatology services may benefit from reviewing their coding practices and documentation processes to ensure claims accurately reflect the services provided.
PEPPER Reports Returning for Medicare Facilities
CMS has announced the upcoming relaunch of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) for all Medicare facility types, including hospitals, post-acute care providers, and specialty facilities.
PEPPER is a free analytical tool designed to help organizations evaluate their Medicare billing patterns and identify areas that may warrant additional review. While PEPPER does not indicate wrongdoing, it can help facilities recognize trends that could attract audit attention or signal opportunities for process improvement.
Some of the insights PEPPER can provide include:
- Billing patterns that differ from national benchmarks.
- Potential under-coding or over-coding trends.
- Areas that may benefit from internal audits or compliance reviews.
- Utilization and length-of-stay patterns that warrant monitoring.
Preparing for the PEPPER Relaunch
Facilities should begin preparing now by confirming that the appropriate staff have access to the PEPPER Portal. Access is managed through the CMS Identity & Access (I&A) System and may require approval from an organization’s Authorized Official or Access Manager.
Ensuring access is established before reports become available can help organizations take advantage of the data as soon as it is released.
Resource: In This Edition: Facility Reports | Laboratory Reporting | DMEPOS Benefit Categories