by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
According to the OIG "MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES."
So often we think if we get paid, we must be doing it right, well this is not always the case. You may get paid and then have to return the funds if billed incorrectly or a step was missing from your compliance plan.
Do you have a compliance plan when it comes to claims processing? If not, I suggest you get it started. If you do, it is important to review it often to ensure there is nothing missing. To get started, take a look at your highest-paid claims, or highest volume and start there. Be sure there are processes at each step of the way, from the first phone call before the patient is seen to the last visit. In the case of neurostimulators, CMS has information on what is needed in the medical record to avoid take-backs.
CMS reported, "In a recent report, the Office of Inspector General found that Medicare improperly paid claims for implanted spinal neurostimulators when providers didn’t provide sufficient documentation supporting medical necessity. For dates of service on or after July 1, 2021, you must ask your Medicare Administrative Contractor to authorize these services before performing the procedure in the hospital outpatient department."
Implanted Spinal Neurostimulators: Document Medical Records
Learn what you need to include in-inpatient medical records:
- Prior Authorization and Pre-Claim Review Initiatives webpage
- Section XVII Calendar Year 2021 Hospital Outpatient Prospective Payment System final rule
- Section 22.214.171.124 Prior Authorization Program for Certain Hospital Outpatient Department Services (PDF) operational guide
- 2021 Final List of Outpatient Department Services That Require Prior Authorization (PDF)