Glitches in outpatient PPS could cause claims errors
Glitches in outpatient PPS could cause claims errors
The Health Care Financing Administration (HCFA) announced that it won’t need its contingency plan that was to take effect if its systems weren’t processing claims under the new hospital outpatient prospective payment system (PPS). However, the system has hit a number of glitches, HCFA reports.
"It is likely that some of these will result in claims processing errors," HCFA posted on its Web site (www.hcfa.gov).
At press time, HCFA expected "virtually all" of the glitches to be addressed by Oct. 1, 2000.
The agency also has announced an increase in the interest rate for overpayments and underpayments. The rate of 13.875% became effective Aug. 1. The previous rate was 13.75%.
The outpatient PPS for hospitals went into effect Aug. 1. The final ambulatory surgery center PPS rule is expected to be published November 2000 and take effect April 2001.
In other news, the American Hospital Association (AHA) in Chicago says payment volumes are shrinking under the outpatient PPS. There are several contributing factors, according to experts cited by the AHA. One is that HCFA appears to be taking longer than the usual 14 days to process some claims. In addition, previous corrections by HCFA, along with the unfamiliarity of the new system, makes errors more likely, the experts say. Some hospitals are holding back some bills until they determine how well the outpatient PPS is working. Some of those hospitals have stopped asking for front-end co-payment, the AHA reports.
"In terms of how things are going, we are being cautious here," says Penny Dykstra, RN, BS, CNOR, director of outpatient services at Saint Joseph’s Hospital of Atlanta. "We couldn’t send in claims until after [Aug.] 14th as instructed, and we elected to hold for another week hoping they’d have their act together."
Some providers also are reporting delays in obtaining software. "Our IS vendor will not have software to us until later this fall, with an expectation to go live’ in March." she says. Saint Joseph’s has worked around the problem, but at press time, the facility was unable to run claims through grouper software prior to sending in claims.
Here is an excerpt of the glitches that HCFA announced:
1. Standard system maintainer issues.
- The Fiscal Intermediary Standard System (FISS) is rejecting claims with condition code G0 as duplicates. These claims should be processed for payment. At press time, a fix was scheduled for implementation at the intermediaries the week of Aug. 28, 2000.
- The FISS receives an error code E6101 from the Common Working File (CWF) because the total charge line is not equal to the sum of the revenue lines on a claim. The claim is being rejected to the contractor suspense file until a fix can be implemented for this problem. At press time, a fix was scheduled for implementation at the intermediaries the week of Aug. 28.
- In the FISS system, a surgical claim that contains two revenue lines for surgery with charges displayed on line one and no charges on line two will pay correctly. Even though the payment is correct, the Medicare Summary Notice does not reflect complete data. This gives the beneficiaries incomplete information regarding the deductible and coinsurance information. At press time, a fix was scheduled for implementation at the intermediaries during the week of Sept. 4.
- The CWF (national file of Medicare claims) system generates an error code when PPS outlier payments are involved. At press time, the claims were to be suspended until the problem was corrected; the CWF maintainer was working on this problem and was scheduled to have it resolved the week of Aug. 28. Once the problem is fixed, the suspended claims will be released for normal processing.
2. Outpatient Code Editor (OCE) issues.
Certain OCE issues discussed below might affect payment to providers or are significant enough that HCFA decided to bring it to providers’ attention.
HCFA will be making modifications to the OCE software to correct these problems. Claims with dates of service on or after Aug. 1, 2000, but received before implementation of these modifications in HCFA’s systems, will experience problems as indicated. To the extent that processing errors occur due to the HCFA standard systems or HCFA’s OCE, HCFA will be responsible for reviewing claims processed for the dates of service in question and making any necessary adjustments.
OCE issues scheduled for resolution no later than Oct. 1, 2000:
- Edit 17 (inappropriate specification bilateral procedure).
Some claims with multiple occurrences of the same bilateral procedure may have more than one bilateral procedure paid. If the same type "T" procedure is reported multiple times on the same line item, the OCE is not rejecting all but one of the bilateral procedures as it should. When the multiple bilateral procedures are reported on separate line items, the OCE is working correctly.
- Revenue codes without HCPCS.
OCE currently assigns a line status indicator of "A" (services not paid under PPS) to some revenue codes without a HCFA Common Procedural Coding System (HCPCS) code. These should be packaged in the PPS payment. - Nonpayable HCPCS codes.
Currently the OCE does not assign a reason code for some nonpayable HCPCS codes.
- Multiple edits issued for same HCPCS code.
Currently the OCE issues two different edits for some HCPCS codes. In the future only one edit will be generated. This may affect the timeliness of payment to the providers to some limited degree.
OCE issues scheduled for resolution no later than January 2001:
Some issues were only recently identified and cannot be fixed in the October version of the OCE. HCFA says claims for these services that are incorrectly processed will be reprocessed as soon as an OCE fix can be installed. As noted, HCFA will fix these problems on or before Jan. 1, 2001. If the fix is made prior to Jan. 1, HCFA will amend this posting to reflect the date of correction.
- Modifier 52 (reduced services).
Claims containing Modifier 52 with type T procedures are being inappropriately discounted in the OCE.
- Modifiers 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), and 79 (unrelated procedure or service by the same physician during the post-operative period).
Claims containing these modifiers are being inappropriately discounted in OCE. (For more pointers from HCFA, see story, below. For information on provider-based rule, see box, at left.)
EXECUTIVE SUMMARY
The Health Care Financing Administration (HCFA) won’t need its contingency plan that was to take effect if its systems weren’t processing claims under the new hospital outpatient prospective payment system (PPS). However, the system has hit a number of glitches, most of which HCFA expected to address by Oct. 1, 2000. (See excerpt of list in story.)
- The American Hospital Association says payment volumes are shrinking under the outpatient PPS due to several factors, including the fact that HCFA appears to be taking longer than the usual 14 days to process some claims.
- HCFA’s interest rate for overpayments and underpayments was increased to 13.875% effective Aug. 1.
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