Blog Archives

Common Medicare Billing Errors Found in Hospitals: Analogous to Medicaid?

Concurrent with the onslaught of Medicaid audits by North Carolina, Department of Health and Human Service (DHHS), Division of Medical Assistance (DMA), the federal HHS Office of Inspector General (OIG) is conducting its own Medicare audits.  While, obviously, Medicare and Medicaid target different populations, many of the federal regulations are analogous.  So I thought it would be prudent to point out some common errors HHS is finding in hospital billing as to Medicare.

According to the Report on Medicare Compliance (RMC), (to which, I am sure, everyone reading this blog subscribes), the three most common errors the OIG auditors are finding are as follows:

  • Emergency Department (ED) admission source codes for psychiatric admissions
  • Lupron (HCPCS code J1950)
  • Tooth extractions (HCPCS D7140)
  • Lymphocyte donor cell infusions (CPT 38242)

Obviously, the common errors for Medicaid billing may be different.  For example, I know that Medicaid auditors are specifically reviewing records for short inpatient stays at hospitals; whereas any issue with records for short stays was not included by the RMC as a common error.

However, that said, I would be willing to bet the ED admission code errors for psychiatric admissions would be just as common in Medicaid as Medicare. 

Most of the errors for admissions’ codes relate to inner-transfer of patients within the hospital (such as Patient X came in complaining of A, but gets transferred to be treated for D).

Remember, though, keep this audit stuff in perspective.  The amount of documents that an auditor must review is enormous.  Some providers are going through multiple audits at the same time.  The auditors, generally, give short turnaround times for the providers to gather the documents and send the documents to the auditor, sometimes 10-15 days. (I have seen 5 days a couple of times).  So, now imagine the sheer volume of documents, the complexity of the Medicaid policies and rules, and the amount of human error on the part of the auditor…add those together for an unattractive sum.

Just by way of example, RMC stated that a hospital last year received 3,400 medical-records requests (That is not the number of records that were requested; that is the number of records request.  Each records request could be many records). This hospital’s records requests were increased last year from 1800 in 2011.

So, while the auditors are looking for document errors in millions of records, make sure the auditor is not making errors in reviewing the millions of documents.