Federal Reports

The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote correct coding by providers and to prevent Medicare payments for improperly coded services. The NCCI edits include procedure-to-procedure edits that define pairs of HCPCS/Current Procedural Terminology codes (code pairs) that generally should not be reported together for the same beneficiary on the same date of service. One function of the procedure-to-procedure edits is to prevent payments for codes that report overlapping services except in those instances where the services are "separate and distinct" (e.g., different session or patient encounter). Typically, an NCCI edit would prevent the payment for a right heart catheterization (RHC) when billed on the same claim as a heart biopsy. However, under certain circumstances, a hospital may bill and get paid for both services in an NCCI code pair by including a modifier on the claim. If a hospital included modifier -59, it would bypass the NCCI edit and receive payment for both procedures as though they were performed separately. A hospital should not append modifier -59 to the HCPCS code representing an RHC when it is performed with a heart biopsy unless the procedures are separate and distinct.

University of Florida Health Jacksonville (the Hospital) complied with Medicare billing requirements for 133 of the 154 inpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 21 claims, resulting in net overpayments of $64,000 for the audit period. These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of our sample results, we estimated that the Hospital received overpayments of at least $273,000 for the audit period.

Blue Cross Blue Shield Association, a terminated Medicare contractor, overstated the Medicare segment pension assets by $1 million as of September 30, 2015. In addition, Blue Cross Blue Shield Association understated Medicare's share of the Medicare segment excess pension assets by $161,000 as of September 30, 2015, as a result of the contract termination.

Blue Cross Blue Shield Association did not claim allowable pension costs of $362,000 for Medicare reimbursement for fiscal years 2011 through 2015.