July 29, 2013

DRILL DOWN - July 2013 Pre-Payment Review for MS-DRGs

 As part of the Pre-payment Demonstration Project for Medicare, the July 2013 target for RAC contractors will be MS-DRGs 391-392 which addresses Digestive Disorders such as esophagitis, gastroenteritis as well as other miscellaneous digestive disorders. RAC contractors should be posting these review issues to their websites soon.

As mentioned in my previous pre-payment article (Drill Down - Pre-Payment Reviews and Short Stays: http://www.racmonitor.com/rac-enews/1429-pre-payment-reviews-and-short-stays.html), pre-payment reviews are complex review types and will require the provider to submit documentation before a payment or denial is made. The RAC will be looking for 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.

 

Pre-payment Audit Workflow

·         ADRs will come from the FI/MAC

·         Providers will have 30 days to send documentation

·         Recovery Auditors will review and communicate payment determination to FI/MAC

–        Providers will receive determination within 45 days

–        RAC will also send detailed review results letter

·         Providers may appeal the denial

–        Same appeal rights as other denials

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/RecoveryAuditPrepaymentReview.html

 RAC issues for the week of July 29 – August 2, 2013:

No issues were posted by RAC contractors.

 

July 22, 2013

Drill Down – Excessive Units Billed for Zoledronic Acid

 It has been a quiet week for the RAC contractors as far as posting approved issues is concerned.  Only RAC Region A Performant posted an automated audit issue for outpatient hospital providers for Zoledronic Acid, Zometa®, HCPCS code J3487, billed in excess of the standard intravenous infusion dosage of 4 mg, per day, per patient.

Per the Novartis Pharmaceuticals literature referenced by the RAC contractor for this issue, Zoledronic Acid is in a group of medicines called bisphosphonates and it works to inhibit the release of calcium in the bones. It is used to treat high blood levels of calcium caused by cancer. Zoledronic Acid also treats multiple myeloma (a type of bone marrow cancer) or bone cancer that has spread from elsewhere in the body.

Zometa is injected into a vein through an IV. This injection is performed in a clinic or hospital setting since it must be administered slowly and can take at least 15 minutes to complete.

Due to the risk of clinically significant deterioration in renal function, which may progress to renal failure, single doses of Zometa should not exceed 4 mg and the duration of infusion should be no less than 15 minutes. In the trials and in post-marketing experience, renal deterioration, progression to renal failure and dialysis, have occurred in patients, including those treated with the approved dose of 4 mg infused over 15 minutes. There have been instances of this occurring after the initial Zometa dose.

 

DOSAGE FORMS AND STRENGTHS

·         4 mg/100 mL single-use ready-to-use bottle

·         4 mg/5 mL single-use vial of concentrate

This automated review will be targeting HCPCS code J3487 on claims for units greater than 4 mg, per day, per patient. For this issue, Performant references such resources as the Centers for Medicare & Medicaid Services (CMS) publications: Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.6 along with the Local Coverage Determination (LCD) Article “Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents.”  

RAC issues for the week of July 22^nd – July 26^th, 2013:

RAC Region A Performant

Outpatient Hospital Claim Types

 

§  Zoledronic Acid (Zometa®) Excessive Daily Units - J12 - Zoledronic Acid (Zometa®) (HCPCS code J3487) billed in excess of the standard intravenous infusion dosage of four units (4 mg), per day, per patient.

July 15, 2013

Drill Down – IRF Coverage Criteria Are You Covered?

 

RAC region A contractor Performant  posted a Complex audit review issue based on Inpatient Rehabilitation Facility (IRF) Admission  for the states of: CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI and VT.

The issue is that IRF benefits are designed to provide intensive rehabilitation therapy in a facility for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach. Performant’s complex review will determine if the patient met the coverage criteria for the admission to the IRF.

The complete list of coverage criteria can be found in 42 CFR 412.604. Some examples for conditions for payment under prospective payment system for inpatient rehabilitation facilities are:

·         The patient actively participates in an ongoing therapeutic intervention of multiple therapies (physical, occupational, speech-language, or prosthetics/orthotics).

·         The patient can actively participate in 3 hours of therapy per day 5 days a week or 15 hours of intensive therapy 7 days a week.

·         Requires physician face to face visits with the patient who is a rehabilitation physician.

·         Requires a comprehensive preadmission screening by a licensed clinician designated by the rehabilitation physician preceding   48 hours of admit.

·         Interdisciplinary team approach to care, with documented meetings and plan of care.

The OIG office has cited criteria for those patients that do not need IRF care as outlined in the Centers for Medicare & Medicaid Services (CMS) Publication Medicare Benefit Policy Manual 100-02 Chapter 1, Section 110 as:

·         Uncomplicated hip or knee surgery or other single joint replacement that requires only pain medication and simple therapy.

·         Simple orthopedic injuries and medical neurological conditions that require only general muscle strengthening and reconditioning.

In the above cases, pre-admission screening procedures did not identify consistently those patients who could be treated in a less intensive facility or those who were not capable of significant improvement as a result of therapy or unable to participate fully in an IRF.

RAC issues for the week of July 15^th – July 19^th, 2013:

RAC Region A Performant

Inpatient Rehabilitation Facility Claim Types

 

§  Inpatient Rehabilitation Facility (IRF) Admission - The IRF benefit is designed to provide intensive rehabilitation therapy in a facility for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach. The review will determine if the patient met the coverage criteria for the admission to the IRF.

July 9, 2013

Drill Down – Blepharoplasty: Necessary or Cosmetic?

 

In the past week, all the RAC region contractors have posted surgical procedure Blepharoplasty as an approved complex audit review.  At issue is whether or not the procedure was done to correct a deficit or for cosmetic reasons.

Blepharoplasty is the repair of the eyelid, and refers to an operation in which extra skin, muscle, and/or fat are removed. Functional blepharoplasty involves the excision of skin and orbicularis muscle. Blepharoplasty is 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 the 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 by Medicare.

The issue references the Medicare Claims Processing and Benefit Policy manuals and the Local Coverage Determination policy for Blepharoplasty outlining guidelines for coding, documentation and medical necessity criteria.

Medicare reimbursement is considered only for those procedures meeting the definition of reconstructive surgery and when the procedure is deemed medically necessary. Cosmetic surgery is not a covered service under Medicare.

 RAC issues for the week of July 8^th – July 12^th, 2013:

 

RAC Region A Performant

DME Supplier Claim Types

 

§  Glucose Monitors Unbundling - Jurisdiction A - HCPCS codes A4233, A4234, A4235, A4236, A4256, and A4258, which describe glucose monitor supplies, will be denied when billed with the same date of service as glucose monitor HCPCS codes E0607, E2100 or E2101, as indicated in NHIC's Local Coverage Determination (LCD) L11530 and related Article A33614.

 RAC Region B CGI

Outpatient Hospital Claim Types

 

§  Outpatient Hospital Annual Wellness Visit Reported More than Allowed – WPS - The Annual Wellness Visit (AWV), either Initial or Subsequent, are only allowed to be reported no more than once per year per beneficiary. There are instances where professional and institutional claims are submitted for the AWV on the same date of service resulting in an overpayment of services.

RAC Region D HDI

Professional Services (Physician/Non-Physician Practitioner) Claim Types

 

§  Maximum Allowed Units for Part B Drugs and Biologicals - Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code descriptor. Palmetto GBA has developed maximum allowed units (MAU), modeled from the medically unbelievable edits (MUE) implemented by CMS. Drugs and biologicals submitted with quantities that exceed the Palmetto GBA established maximum limits will be denied unless additional supporting documentation is submitted for consideration.

July 2, 2013

Drill Down – Portable and Stationary Oxygen Systems

 RAC Region A contractor Performant is targeting DME suppliers this week with regard to portable oxygen and stationary oxygenators. 

Claims for portable oxygen systems – HCPCS codes E0431, E0433, E0434, E1392, and K0738 – will be denied when billed with stationary oxygen systems – HCPCS codes E0424, E0439, E1390, E1391 – that are paid at a higher allowance for a flow-rate greater than 4 liters per minute as indicated in the Oxygen and Oxygen Equipment Local Coverage Determination (LCD) and Article.

Per coverage information, payment for stationary equipment is increased for beneficiaries requiring greater than 4 liters per minute of oxygen flow and decreased for beneficiaries requiring less than 1 liter per minute. If a beneficiary qualifies for additional payment for greater than 4 liters per minute of oxygen and also meets the requirements for portable oxygen, payment will be made for the stationary system at the higher allowance, but not for the portable system. In this situation, if both a stationary system and a portable system are billed for the same rental month, the portable oxygen system will be denied as not separately payable. 

Performant will be conducting an automated review of DME claims for beneficiaries that were paid for both types of equipment in the same month when only one equipment type should have been paid at a higher allowance. 

 

RAC issues for the week of July 1^st – July 5^th, 2013:

 RAC Region A Performant        

 DME Supplier Claim Types

 

§  Portable Oxygen System Paid with Stationary Oxygen System Allowed for a Flow Rate Greater Than 4 Liters per Minute (LPM) - Jurisdiction A - Claims for portable oxygen systems (HCPCS codes E0431, E0433, E0434, E1392, and K0738) will be denied when billed with stationary oxygen systems (HCPCS codes E0424, E0439, E1390, E1391) that are paid at a higher allowance for a flow rate greater than 4 liters per minute (LPM), as indicated in NHICs' Local Coverage Determination (LCD) L11468 and related Article A33768.

 RAC Region B CGI

Inpatient Claim Types

 

§  Post-Acute Transfer - NGS - The purpose of this automated review is to identify patient discharge status codes improperly reported under Medicare’s Inpatient Prospective Payment System (IPPS) Transfer Policy. This policy applies to all DRGs using the patient discharge status code 02, and specified DRGs using patient discharge status codes 03, 05, 06, 62, 63, and 65. Under the transfer policy, the initial acute care facility shall be paid a per diem rate (up to the full DRG) and the receiving facility shall be paid the full DRG payment. Claims reported as discharge status 01 (to home) rather than as a transfer or claims reported as a transfer reported incorrectly would result in improper payment.        

 Outpatient Hospital Claim Types

 

§  Outpatient Hospital Annual Wellness Visit Reported on SAME Day More than Allowed - NGS - The Annual Wellness Visit (AWV), either Initial or Subsequent, are only allowed to be reported no more than once per year per beneficiary. There are instances where professional and institutional claims are submitted for the AWV on the same date of service resulting in an overpayment of services.

 

RAC Region C Connolly  

Physician Claim Types

 

§  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.

§  Intensity-Modulated Radiation Therapy (IMRT) - 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.

 

 

RAC Region D HDI

 Professional Services (Physician/Non-Physician Practitioner) Claim Types

§  Intensity-Modulated Radiation Therapy (IMRT) - 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.

June 25, 2013

Drill Down – Intensity Modulated Radiation Therapy (IMRT)

 All four RAC contractors have issued a complex review on July 18^th targeting Intensity Modulated Radiation Therapy (IMRT) for Physicians and Non-Physician Practitioners. IMRT is a powerful computer based program that delivers radiation to a portion of a field depending on the tumor or critical structures near the tumor that is present in the radiation pathway.

These are multiple thin beam, pencil like, that affect the tumor with high doses of radiation however leaving normal structures unaffected and using much lower doses of radiation, thus modulated.

The audit  is looking for medical necessity in this and whether or not the diagnoses on the claim is listed in the Local Coverage Determination (LCD).

When checking the claim against the medical record, look at the Coverage Indications Limitations and/or Medical Necessity and Coding Information sections in the LCD that describes the conditions that need to be met in order to satisfy medical necessity and ICD/CPT combinations. The General Information section of the LCD lists the documentation requirements, which are quite robust for IMRT: prescription of the treatment plan, need for performing the IMRT, approved IMRT inverse plan (PTV), target verification methodology and documentation, immobilization and positioning documentation, monitor units, fluence distribution in the phantom, respiratory motion.

The audit also references CMS publications 100-02 Medicare Benefit Policy Manual, 100-04 Medicare Claims Processing Manual and 100-09 Medicare Contractor Beneficiary and Provider Communications Manual.

 RAC issues for the week of June 24^th – June 28^th, 2013:

RAC Region A Performant        

Ambulatory Surgical Center Claim Types

 

§  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.

 

Physician/Non-Physician Practitioner 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.

§  Annual Wellness Visit (AWV) - J13 - Annual Wellness Visit (AWV) billed more than once in a lifetime, initial.

RAC Region B CGI

Inpatient Claim Types

 

§  Post-Acute Transfer - WPS - The purpose of this automated review is to identify patient discharge status codes improperly reported under Medicare’s Inpatient Prospective Payment System (IPPS) Transfer Policy. This policy applies to all DRGs using the patient discharge status code 02, and specified DRGs using patient discharge status codes 03, 05, 06, 62, 63, and 65. Under the transfer policy, the initial acute care facility shall be paid a per diem rate (up to the full DRG) and the receiving facility shall be paid the full DRG payment. Claims reported as discharge status 01 (to home) rather than as a transfer or claims reported as a transfer reported incorrectly would result in improper payment.

§  Blepharoplasty - Eyelid Lifts (Medical Necessity) - 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 criteria of the functional visual impairment parameters and is considered not reasonable and medically necessary and therefore will be denied.

§  Intensity-Modulated Radiation Therapy (Medical Necessity) - 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.

§  Cancelled Elective Surgeries (Medical Necessity) - 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.

 

RAC Region C Connolly  

 Inpatient Hospital Claim Types

 

§  Cancelled Elective Surgeries - 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

§  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.

§  Intensity-Modulated Radiation Therapy (IMRT) - 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.

 

RAC Region D HDI

 Critical Access Hospital Claim Types

 

§  Intensity-Modulated Radiation Therapy (IMRT) - 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 (CAH) - 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 Acute Care Hospital Claim Types

 

§  Cancelled Elective Surgeries - 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.

§  Intensity-Modulated Radiation Therapy (IMRT) - 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 (Acute Inpatient Hospitals) - 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.

 

Outpatient Hospital Claim Types

 

§  Intensity-Modulated Radiation Therapy (IMRT) - 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.