Medicare Edit Issues in Medical Coding

We had a question come in about having a Medicare edit issue with multiple procedures on one claim for a series encounter that spans multiple dates of service. So this is for a critical access hospital. So, there’s a little bit more on the answer sheet that we have.
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So they’re having a problem because the codes are in the surgical range that they’re having problems with and they’re hitting NCCI edits in their Direct Data Entry that they do. They have a WPS Medicare. So, saying that they should be rolled into one and they’ve never had to do this in the past because each procedure was on a different Date of Service. So the Medicare MAC should be just be able to tell that there are different procedures because they’re on different dates of services. They’ve contacted their MAC carrier and they’ve gone to high-level supervisors who say everything’s fine so they’re just kind of looking for any more insight that we might have. Now, I’ve never critical access hospital so this took a lot of research to figure out. I do mainly everything outpatient.
Now, Critical Access Hospital is a rural hospital that has to be more than 35 miles from another hospital. So talking of rural area, they’re small. They have 25 or less acute inpatient beds. So, it’s a small facility we’re talking about. Typical stay is usually 96 hours or less. So, either discharge them or they’re going to transfer them onto another facility. They can stay longer than that. Medicare has restrictions or criteria for them to stay longer than that, that need to be met. But otherwise, it’s just something to have available in a rural area for when there’s a problem.
There are two ways Critical Access Hospital can bill. They have Method I: Professional medical services, like a doctor coming in to see the patient, the professional services, providers coming are furnished on CMS-1500, go to Part B and the facility goes to Part A. That’s usually a standard format for services. So, you have a provider who comes in, a neurologist or cardiologist, something like that. They have an outside office that they usually work in. They’re coming in to see this patient and take a look at him. They’re going to bill their professional services on the CMS-1500 and the whole time the patient’s in the hospital, all those services are going to Part A on a UB-04 form.
There’s Method II: Critical Access Hospital bills Part A for both facility and professional services. So, everything is being rolled into one. Each services has revenue codes that go with CCI and Medically Unlikely Edits. Those guidelines, they’re still followed. The same surgical rules apply. So, your global periods are also going to apply. Even though you’re billing kind of this all thing together - Part A everything together. The professional then they signed over to the hospital that they are not going to bill these services. Their money is going to go to the hospital and then they would get paid that way.
The only notations I can find that could help with this concern is there is a preadmission bundling requirement that if the patient is admitted on the same day or within 3 days of any outpatient service, they require separate claims.
So, possibly something was bumping up there. There’s also a repetitive billing feature. So, if some of these services, say, were physical therapy or chemotherapy, radiology, some kind of repetitive thing that they’re going to do each day then they were asking for them to all be billed in one line with your from and to day or two and from. To and from, so you’ve got 4 days on there, however many. January 1st to January 5th with your physical therapy services.This note didn’t say what kind of services these were. They just said CPT surgical. I understand they’re running up against edits. So they say that the global period still applies though. So, we’re looking providers seeing a patient and this was treated like an outpatient hospital.
That’s another rule that it says when you’re looking up… Medicare’s rules regarding Critical Access Hospitals that you might have another doctor coming in to take a look at him on that same day perhaps. That another service… Well, they’re going to apply those global service rules. So, even though it’s not the same doctor, if they’ve signed over all their benefits to the hospital then they could be bumping up against tax ID issues. It could require items all to be on one line. There was no definitive. I went to WPS. T\