September 23, 2013

Drill Down – Continuous Passive Motion Devices

RAC Region D contractor Health Data Insights posted an issue on September 13, 2013 for Durable Medical Equipment (DME)/Non-Physician providers regarding the use of Continuous Passive Motion (CPM) Device without evidence of a preceding knee replacement surgery. The CPM Device is being targeted when used in the patient’s home without the patient having a documented knee replacement surgery. The Centers for Medicare & Medicaid Services (CMS) publication, 100-03 Medicare National Coverage Determinations Manual - Chapter 1, Section 280.1, lists the allowed usage of a Continuous Passive Motion Device as 2 days after inpatient surgery and is limited to use 3 weeks after surgery while the patient recovers at home.

 

Source: http://en.wikipedia.org/wiki/Continuous_passive_motion

 Per the CMS publication, 100-04 Medicare Claims Processing Manual - Chapter 20, Section 30.2.1, the HCPCS code of E0935 is used to bill for CPM devices. Medicare contractors make payment for each day that the device is used in the patient's home. No payment can be made for the device when the device is not used in the patient's home or once the 21 day period (3 weeks) has elapsed. It is possible for a patient to receive CPM services in their home on the date that they are discharged from the hospital, this date counts as the first day of the 3 week limited coverage period.

RAC issues for the week of September 23 – September 27, 2013:

RAC Region B CGI

Inpatient

§  Other Vascular Procedures with MCC MS-DRG 252 (Medical Necessity Excluded) - MS-DRG validation requires that diagnostic and procedural information, present on admission indicator 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. Reviewer will validate for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG were met per Medicare guidelines.

RAC Region D HDI

DME/Non-Physician

§  CPM device without a total knee replacement - Continuous Passive Motion (CPM) coverage is limited by Medicare to a total of 21 days following a total knee replacement: claims paid for CPM devices without evidence of a preceding total knee replacement are overpayments.

Inpatient Acute Care Hospital

§  Incorrect Pt Status - Acute Underpayments - Acute hospitals have billed incorrect discharge statuses when a patient is transferred to another facility. The reimbursement for the acute hospital was underpaid based on the type of facility the patient was subsequently transferred to or the absence of any subsequent facility claim.

§  Pre-payment Review of MSDRG 391 - 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 391, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.

 Inpatient Rehab Facility

§  Incorrect Pt Status - IRF Underpayments - Inpatient Rehab Hospital stays that have billed an incorrect discharge status after transferring a patient to another facility. The reimbursement for the inpatient rehab hospital was underpaid based on the type of facility the patient was subsequently transferred to or the absence of any subsequent facility claim.

Outpatient Hospital

§  Excessive Units of Total Mastectomy - J1 - CPT codes for Total Mastectomy services are allowed only once per breast.

§  Excessive Units of Endovascular Revascularization of the Femoral/Popliteal Territory - J5 and Legacy - Only one code within the range of 37220-37235 should be reported for endovascular revascularization for each extremity vessel treated. The entire femoral/popliteal territory in one lower extremity is considered a single vessel for CPT reporting specifically for the endovascular lower extremity revascularization codes 37224-37227. Therefore, CPT codes in this range may only be reported once per lower extremity.

§  Excessive Units of Endovascular Revascularization of the Femoral/Popliteal Territory - Only one code within the range of 37220-37235 should be reported for endovascular revascularization for each extremity vessel treated. The entire femoral/popliteal territory in one lower extremity is considered a single vessel for CPT reporting specifically for the endovascular lower extremity revascularization codes 37224-37227. Therefore, CPT codes in this range may only be reported once per lower extremity.

Skilled Nursing Facility

§  Multiple 14 day assessments billed during a SNF stay - J1 (OIG) - The “14 day” Medicare MDS Assessment Type authorizes coverage and payment for a maximum of 16 days.

§  Excessive Units SNF 90 day assessment - J1 - The “90 day” Medicare MDS Assessment Type authorizes coverage and payment for a maximum of 10 days.

§  Excessive Units SNF 5 day assessment - The “5 day” Medicare MDS Assessment Type authorizes coverage and payment for a maximum of 14 days.

September 17, 2013

Drill Down – Home Health Consolidated Billing and Therapy Services

 RAC Region A contractor Performant posted an automated review on August 15, 2013 for Outpatient Hospital therapy claims for patients under Home Health plan of care. Therapy services (physical, occupational and speech and language) are bundled into the Home Health Prospective Payment Systems with reimbursement paid to the Home Health agency only and no separate payment is made to outpatient hospital therapy provider.

Before a provider of therapy services initiates those services to the Medicare beneficiary, the provider would need to determine whether or not a Home Health episode of care exists for that beneficiary.  This audit issue references the Centers for Medicare and Medicaid (CMS) Medicare Benefit Policy and Medicare Claims Processing Manuals.

A therapy provider should ask the beneficiary or their authorized representative, if he/she is presently receiving Home Health services under a home health plan of care. Beneficiaries and their representatives should have the most complete information regarding Home Health care status. Therapy providers may document information from the beneficiary that states the beneficiary is not receiving Home Health care but such documentation in itself does not shift liability to either the beneficiary or Medicare for any denied claims.

To determine if the Medicare beneficiary is under Home Health plan of care, contact the Medicare contractor’s toll free number to request Home Health eligibility. Institutional providers (providers who bill using the institutional claim format) may access this information electronically through the Home Health Common Working File (CWF) inquiry process. Independent therapists or suppliers who bill using the professional claim format also have access to a similar electronic inquiry via the HIPAA standard eligibility transaction – the 270/271 transaction.

As an aid to suppliers and providers subject to Home Health consolidated billing, Medicare systems display, for each Medicare beneficiary, the code for certification (G0180) or recertification (G0179) and the date of service for either of the two codes.

 RAC issues for the week of September 16 – September 20, 2013:

RAC Region A Performant

Independent Therapy Provider

§  Home Health Consolidated Billing and Therapy Services - JL - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (A) (Home Health Services Consolidated Billing), therapy services (physical, occupational, and speech-language pathology) are bundled into the Home Health Prospective Payment System (HH PPS) reimbursement made to the Home Health Agency (HHA), while the patient is under a home health plan of care. Medicare does not make separate payment made to the independent therapy provider.

Outpatient Hospital

§  Trastuzumab (Herceptin®), Multi-dose Vial Waste - Per its package label, Trastuzumab (Herceptin®) is supplied by the manufacturer in a 440 mg multi-dose vial. Per Medicare Claims Processing Manual (100-04) Chapter 17, §40: "When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. Note: Multi-use vials are not subject to payment for discarded amounts of drug or biological."

Physician/Non-Physician Practitioner

§  Trastuzumab (Herceptin®), Multi-dose Vial Waste - Per its package label, Trastuzumab (Herceptin®) is supplied by the manufacturer in a 440 mg multi-dose vial. Per Medicare Claims Processing Manual (100-04) Chapter 17, §40: "When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. Note: Multi-use vials are not subject to payment for discarded amounts of drug or biological."

§  Maximum Allowed Units for Part B Drugs and Biologicals - JL - Potential incorrect billing occurred for claims billed in excess of the maximum allowed units for Part B drugs and biologicals, when no additional supporting documentation is received from the provider for complex review within the 45-day response period.

§  Billing for Dead Beneficiaries - Jurisdiction K - Medicare does not pay for services provided after the beneficiary's date of death.

§  Billing for Dead Beneficiaries - Jurisdiction L - Medicare does not pay for services provided after the beneficiary's date of death.