Payments for Outpatient Infusion Therapy and Blood Administration Services Provided at Washington Hospital Center, Washington, DC

摘要

CMS requires providers to bill accurately using the appropriate revenue codes and Healthcare Common Procedure Coding System (HCPCS) codes and to report the correct units of service performed. Revenue codes identify the cost center used on the hospitals annual cost report. HCPCS codes are used to identify and group services into an ambulatory payment classification group. When providers performed multiple procedures for the same beneficiary on the same date of service, the system pays the maximum allowable payment for the first procedure and, generally, half the maximum allowable payment for each additional procedure. For other services, Medicare only pays for one service per day, regardless of the number of procedures performed. Payment for some specific outpatient services is included in the payment for the primary surgical procedure. Medicare refers to these types of services as packaged or bundled services. Medicare does not allow payment of bundled or packaged services on a rate-per-service basis. Washington Hospital Center (the hospital) is a 926-bed acute-care teaching and research hospital located in the District of Columbia. The hospital is a member of MedStar Health, a not-for-profit regional healthcare system. Before October 1, 2005, CareFirst of Maryland was the fiscal intermediary for the hospital. On October 1, 2005, Highmark Medicare Services (Highmark) became the hospitals fiscal intermediary and, subsequently, on October 24, 2007, the Medicare administrative contractor. As the current Medicare contractor for the hospital, Highmark is responsible for collecting overpayments for the hospitals claims. Our objective was to determine whether payments received by the hospital from its Medicare contractor were appropriate for outpatient infusion therapy and blood administration services billed by the hospital.