In Context

Drill Down – Global Period Violations

May 13, 2013

RAC Region A Performant posted a semi-automated review issue on April 25, 2013 targeting    all of Region A states with regard to procedures performed in the postoperative or global period. These would be procedures or surgeries that are performed during the 90 day or 10 day global post-op period of the initial procedure, which Performant considers an overpayment when it is billed without the following:

·         Modifier 58 - this modifier allows for billing a staged or related surgical procedure done during the postoperative  period of the first procedure) or

·         Modifier 78 - describes the services involving a return trip to the operating room to deal with complications or

·         Modifier 79 - reports an unrelated procedure by the same physician during the postoperative period or

·         A clinically appropriate NCCI-associated anatomical modifier that justifies separate payment (i.e., indicating different body areas).

Medicare contractors apply the national definition of a global package to all procedures using the Medicare Fee Schedule Data Base (MFSDB), Column (O) titled Global Days, where the payment rules for surgical procedures apply to codes with entries of 000, 010, and 090. Codes with 090 are major surgeries, and codes with 000 and 010 are minor surgical procedures or endoscopies.  In the sample below, Column (O) titled GLOB DAYS displays the global days for each procedure.

 

 Physician and Non-Physician Practitioners should be aware that performing additional procedures, major or minor, during the global postoperative of the initial procedure will be considered an over-payment if billed without using the appropriate modifiers 58, 78, 79 or a clinically appropriate NCCI-associated anatomical modifier that justifies separate payment.

Other RAC issues for the week of May 13^th - May 17^th, 2013:

RAC Region A Performant

Outpatient Hospital Claim Types

 

§  Nerve Conduction Studies (NCS) - Maximum Units - J12 - Potential incorrect billing occurred for claims reporting CPT codes 95900, 95903 and 95904 for units in excess of what is medically necessary, based on information found in Novitas Local Coverage Determination (LCD) L29547. Payment will be recouped when no additional, supporting documentation is received from the provider for complex review within the 45-day response period.

§  Zoledronic Acid (Zometa®) Excessive Daily Units - J13 - Potential incorrect billing occurred when Zoledronic Acid (Zometa®), HCPCS code J3487, is reported in excess of the standard intravenous infusion dosage of four units (4 mg), per day, per patient.

Outpatient Rehabilitation Facility Claim Types

 

§  Nerve Conduction Studies (NCS) - Maximum Units - J12 - Potential incorrect billing occurred for claims reporting CPT codes 95900, 95903 and 95904 for units in excess of what is medically necessary, based on information found in Novitas Local Coverage Determination (LCD) L29547. Payment will be recouped when no additional, supporting documentation is received from the provider for complex review within the 45-day response period.

 

Physician/Non-Physician Practitioner Claim Types

 

§  Panretinal (Scatter) Laser Photocoagulation Excess Frequency - J13 - Potential incorrect billing occurred for Panretinal Laser Photocoagulation services (CPT code 67228) paid more than once, per eye, within a 90 day global period.

 

RAC Region C Connolly

 Carrier Claim Types

§  Mohs Surgery with Pathology billed by different provider - Mohs micrographic surgery used for removal of complex or ill-defined skin cancer requires physicians to act in two integrated but separate capacities: surgeon & pathologist. If either surgery or pathology is delegated to another physician who reports services separately, Mohs codes should not be reported since they include both the excision and the pathology services.

§  Post-payment Part B Review - Manual Medical Review of Therapy Claims Above the Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

 

Comprehensive Outpatient Rehabilitation Facility Claim Types

 

§  Post-payment Review - Manual Medical Review of Therapy Claims Above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

Home Health Claim Types

 

§  Post-payment Review - Manual Medical Review of Therapy Claims Above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

 

Outpatient Hospital Claim Types

§  Non-Covered use of Arpetitant (J8501) - Coverage for aprepitant (J8501) is predicated by its use as the three drug combination of aprepitant, a 5-HT3 antagonist and dexamethasone, and must be used in conjunction with one or more specified chemotherapuetic agents.

§  Post-payment Review - Manual Medical Review of Therapy Claims Above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

 

Outpatient Rehab Facility Claim Types

 

§  Post-payment Review - Manual Medical Review of Therapy Claims Above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

 SNF Claim Types       

 

§  SNF Coding Validation - C000412013 - We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical Necessity will not be included in this review)                 

§  SNF Coding Validation - C000422013 - We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical Necessity will not be included in this review) 

§  SNF Level of Care Review - C000972013 - While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term “non-covered care” refers to any level of care, which is less intensive than the SNF level of care, which is covered under the program.

§  SNF Level of Care Review - C000982013 - While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term “non-covered care” refers to any level of care, which is less intensive than the SNF level of care, which is covered under the program.      

§  Post-payment Review - Manual Medical Review of Therapy Claims Above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.