Hospitals Nationwide Generally Did Not Comply With Medicare Requirements for Billing Outpatient Right Heart Catheterizations With Heart Biopsies

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.

Hospitals nationwide complied with the Medicare requirements for billing outpatient RHCs and heart biopsies provided during the same patient encounter for 8 of the 100 sampled line items. However, the hospitals did not comply with the Medicare requirements for 92 of the 100 sampled line items. Specifically, the hospitals incorrectly appended modifier -59 to the HCPCS code, representing that the RHCs were separate and distinct procedures from the heart biopsies even though the medical record documentation did not support the use of the modifier. On the basis of our sample results, we estimated that hospitals nationwide received overpayments totaling $7.6 million for the audit period.

We recommended that CMS instruct the Medicare contractors to (1) educate hospitals on how to appropriately bill for RHCs performed during the same patient encounter as heart biopsies, which could have resulted in savings totaling an estimated $7.6 million over a 2-year period; (2) identify claims in the years subsequent to our audit period that did not meet Medicare payment requirements and recover any associated overpayments; and (3) 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. In written comments on our draft report, CMS concurred with our recommendations.