June 17th 2013

Drill Down – Canceled Elective Surgery but not Reimbursement

 This week, RAC Region A contractor Performant has posted a complex audit issue – Canceled Elective Surgeries for Acute Inpatient Hospital providers. Performant is reviewing all canceled elective surgeries that did not occur but the hospital billed for the admission and would be paid only if the surgery was considered reasonable and necessary despite the cancelation of the elective surgery.

What exactly are the elective surgeries? Elective surgery is generally defined as optional surgery performed for non-medical reasons, such as cosmetic. Most medically necessary surgeries such as inguinal hernia surgery, cataract surgery, mastectomy for breast cancer, and the donation of a kidney by a living donor are performed as elective surgeries.

When is a patient considered an “inpatient”? An “inpatient” is a person who has been admitted to a hospital for bed occupancy for purposes of receiving hospital services. A patient is considered an inpatient if formally admitted to the hospital with the expectation that he or she will remain at least overnight and occupy a bed even though later that patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.

Why is this a RAC issue target? Mirroring the OIG Work Plan for 2013, which describes the payment increase when a cancelation and reschedule of a surgery occurs? The OIG will examine payments to hospitals for canceled surgeries which the OIG considers an emerging hot spot issue.

 Hospitals – Payments for Canceled Surgical Procedures

The OIG will determine costs incurred by Medicare related to inpatient hospital claims for canceled surgical procedures. The preliminary analysis of Medicare claims data for inpatient stays demonstrated significant occurrences of an initial PPS payment to hospitals for a canceled surgical procedure followed by a second, higher PPS payment to the same hospitals for the rescheduled surgical procedure. For these claims, the canceled surgical procedure was the principal reason for the initial hospital admission. For these short-stay claims, few, if any, inpatient services (i.e., laboratory or diagnostic tests) were provided by the hospitals because the surgical procedure was canceled. Medicare makes two payments to hospitals that generate two bills unless the patient is readmitted to the hospital on the same day, in which case a single payment is made. The analysis also identified inpatient claims with canceled surgical procedures for stays of less than 2 days that were not followed by subsequent inpatient admissions to the same hospitals for the rescheduled surgical procedures. Current Medicare policy does not preclude payment for these claims.

 RAC issues for the week of June 17^th – June 21^st, 2013:

 RAC Region A Performant        

Critical Access Hospital Claim Types

 

§  Intensity-Modulated Radiation Therapy (IMRT) - Region A - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.

§  Blepharoplasty - Eyelid Lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.

 Inpatient Hospital (Acute) Claim Types

 

§  Cancelled Elective Surgeries - Acute Inpatient Hospital - Region A - When an inpatient hospital admission is based on the expectation that a patient will have elective surgery, but that surgery does not occur, the hospital may bill for the admission only if it remains reasonable and necessary despite the surgery's cancellation.

 Outpatient Hospital Claim Types

 

§  Intensity-Modulated Radiation Therapy (IMRT) - Region A - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.

§  Blepharoplasty - Eyelid Lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.

 RAC Region C Connolly

Inpatient Hospital Claim Types

 

§  CMS Pre-Pay Demonstration: MS-DRG-252-Other Vascular Procedures with MCC - The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: CMS approves all issues for review; and the issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (Fis)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: Billed with MS-DRG-252-Other Vascular Procedures with MCC; Length of stay is two days or less; From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

 

§  CMS Pre-Pay Demonstration: MS-DRG-253-Other Vascular Procedures with CC - The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: CMS approves all issues for review; and the issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (Fis)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: Billed with MS-DRG-253- Other Vascular Procedures with CC; Length of stay is two days or less; From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

§  CMS Pre-Pay Demonstration: MS-DRG-254-Other Vascular Procedures without CC/MCC -The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: CMS approves all issues for review; and The issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (Fis)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: Billed with MS-DRG-254- Other Vascular Procedures without CC/MCC; Length of stay is two days or less; From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

§  IRF Case Mix Group Audit - In order for IRF care to be considered reasonable and necessary, the documentation in the patient’s IRF medical record must demonstrate a reasonable expectation that all five of the rehabilitation criteria were met at the time of admission to the IRF. Billing for acute inpatient rehabilitation services requires the submission of the Case Mix Group (CMG). On Medicare claims these CMGs are represented as HIPPS codes. HIPPS codes are determined based on assessments made using the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI.) The IRF-PAI contains detailed evaluations on the patient’s functional status in 18 critical areas of functional capacity. Therefore the CMG codes contain clinical information about the functional status of the patient on admission to an acute inpatient rehabilitation facility. Certain CMGs suggest patients admitted to acute inpatient rehabilitation with very low functional status as well as high functional status. These two areas of outliers suggest that these patients may not have been appropriate for acute inpatient rehabilitation services and a more detailed review of the chart is warranted.

 

Outpatient Hospital Claim Types

§  J3240 - (Injection, Thyrotropin Alpha, 0.9 mg, provided in 1.1 mg vial) Excessive Use - As per FDA approved drug labeling the recommended dosing regimen for Thyrogen is a two-injection regimen consisting of one intramuscular (IM) dose on day one, followed by a second IM injection 24 hours later (i.e., 2 units per treatment regimen).

June 10th 2013

Drill Down – DME Issue Custom vs. Pre-Fabricated Orthoses

 RAC Region A contractor Performant is targeting DME suppliers for Ankle-Foot Orthoses (AFO) and Knee-Ankle-Foot (KAFO) Orthoses.  AFOs are covered for ambulatory patients with weakness or deformity of the foot and ankle, which require stabilization for medical reasons, and have the potential to benefit functionally. KAFOs are covered for ambulatory patients for whom an ankle-foot orthoses is covered and for whom additional knee stability is required. Both types of devices can be pre- or custom-fabricated.

The issue is that claims for HCPCS codes which describe additions for custom-fabricated orthoses, will be denied when billed with pre-fabricated AFOs and KAFOs HCPCS base codes listed in the Local Coverage Determination (LCD) policy. For custom fabricated orthoses to be even covered by Medicare there must be detailed documentation in the treating physician’s records to support the medical necessity of custom-fabricated rather than a pre-fabricated orthoses. There must be information corroborated by the functional evaluation in the physician’s records and be available upon request.

Codes L1900, L1904, L1907, L1920, L1940-L1950, L1960-L1970, L1980-L2030, L2034, L2036-L2108, L2126-L2128 and L4631 describe custom-fabricated orthoses and must not be used for prefabricated (i.e., non-custom-fabricated) orthoses.

Codes L1902, L1906, L1910, L1930, L1951, L1971, L2035, L2112-L2116, and L2132-L2136 describe pre-fabricated orthoses and must not be used for custom-fabricated orthoses.

To avoid denials on AFO/KAFO claims, the right (RT) and left (LT) modifiers must be used with base codes, additions, and replacement parts. When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using the RTLT modifiers and 2 units of service. Claims billed without modifiers RT and/or LT will be rejected as incorrect coding.

 RAC issues for the week of June 10^th – June 14^th, 2013:

RAC Region A Performant        

 
DME Supplier Claim Types

 

§  Ankle-Foot Orthosis (AFO) and Knee-Ankle-Foot Orthosis (KAFO), Custom vs. Prefabricated - Jurisdiction A - Claims for HCPCS codes L2232, L2320, L2330, L2387, L2755, L2800, L4040, L4045, L4050 and L4055, which describe additions for custom-fabricated orthoses, will be denied when billed with prefabricated Ankle-Foot Orthoses (AFO) and Knee-Ankle-Foot Orthoses (KAFO) HCPCS base codes listed in NHIC's Local Coverage Determination (LCD) L11527 and related Article A19806, and NHIC's LCD L27263 and related Article A46762.

 RAC Region D HDI

 DME Supplier Claim Types

 

§  Pre-Payment Review of MS-DRG 638 - Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MSDRG 638, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.