OIG: Hospitals often do not appropriately bill for certain heart procedures

In 2011 and 2012, hospitals in the U.S. did not often comply with Medicare requirements on how to appropriately bill for right heart catheterizations performed during the same patient encounter as heart biopsies, according to a report from the HHS Office of Inspector General (OIG).

If hospitals had billed those services correctly, the OIG estimates they would have saved $7.6 million during a two-year period.

The OIG mentioned in its report that prior reviews found that some hospitals did not comply with Medicare billing requirements because they incorrectly billed outpatient right heart catheterizations performed during the same patient encounter as heart biopsies. The OIG said that Medicare payments for heart biopsies are typically intended to cover a right heart catheterization when they are performed in the same encounter.

The authors also noted that CMS created the National Correct Coding Initiative (NCCI) in 1996 to prevent Medicare payments for improperly coded services. Although an NCCI edit prevents payment for a right heart catheterization when it’s billed on the same claim as a heart biopsy, the authors noted hospitals sometimes included modifier -59, which leads to payment for both procedures.

For this audit, the OIG analyzed $11.16 million in Medicare payments to 140 hospitals for 6,018 right heart catheterization line items that the authors thought were potentially at risk for billing errors. They then selected a stratified random sample of 100 right heart catheterization line items with payments totaling $182,000 for calendar years 2011 and 2012.

The OIG report found that hospitals failed to comply with Medicare requirements for billing outpatient right heart catheterizations and heart biopsies during the same patient encounter on 92 of the 100 sampled line items. The hospitals incorrectly appended modifier -59 to the HCPCS code, according to the authors.

The hospitals in the sample received overpayments of $122,000. Based on those results, the OIG estimated that hospitals nationwide received an estimated $7.6 million in overpayments in 2011 and 2012.

The OIG recommended that CMS instruct Medicare contractors to “educate hospitals on how to appropriately bill for [right heart catheterizations] performed during the same patient encounter as heart biopsies”; “identify claims in the years subsequent to our audit period that did not meet Medicare payment requirements and recover any associated overpayments”; and “notify providers of potential overpayments so that those providers can exercise reasonable diligence to investigate and return any identified overpayments, in accordance with the 60-day rule, and identify and track any returned overpayments as having been made in accordance with this recommendation.”

The report mentioned that CMS concurred with the OIG’s recommendations.