October 29, 2013

Drill Down – Pre-Admission Services

RAC Region A contractor Performant posted an automated review on October 17, 2013 for the states of Delaware, Maryland, New Jersey, Pennsylvania and District of Columbia, regarding pre-admission services for Outpatient Hospital providers. Per the contractor’s description of this audit issue, diagnostic and non-diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital, within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.

One of the references listed for this issue is the CMS 100-04 Medicare Claims Processing Manual, Chapter 3, Section 40.3:

A. Outpatient Services Followed by Admission Before Midnight of the Following Day (Effective For Services Furnished Before October 1, 1991)

When a beneficiary receives outpatient hospital services during the day immediately preceding the hospital admission, the outpatient hospital services are treated as inpatient services if the beneficiary has Part A coverage. Hospitals and FIs apply this provision only when the beneficiary is admitted to the hospital before midnight of the day following receipt of outpatient services. The day on which the patient is formally admitted as an inpatient is counted as the first inpatient day.

When this provision applies, services are included in the applicable PPS payment and not billed separately. When this provision applies to hospitals and units excluded from the hospital PPS, services are shown on the bill and included in the Part A payment. See Chapter 1 for FI requirements for detecting duplicate claims in such cases.

B. Preadmission Diagnostic Services (Effective for Services Furnished On or After January 1, 1991)

Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage. For example, if a patient is admitted on a Wednesday, outpatient services provided by the hospital on Sunday, Monday, Tuesday, or Wednesday are included in the inpatient Part A payment.

For this provision, diagnostic services are defined by the presence on the bill of the following revenue and/or CPT codes:

 

0254 -	Drugs incident to other diagnostic services
0255 -	Drugs incident to radiology
030X -	Laboratory
031X -	Laboratory pathological
032X -	Radiology diagnostic
0341, 0343 -	Nuclear medicine, diagnostic/Diagnostic Radiopharmaceuticals
035X -	CT scan
0371 -	Anesthesia incident to Radiology
0372 -	Anesthesia incident to other diagnostic services
040X -	Other imaging services
046X -	Pulmonary function
0471 -	Audiology diagnostic
0481, 0489-	Cardiology, Cardiac Catheter Lab/Other Cardiology with CPT codes 93451-93464, 93503, 93505, 93530-93533, 93561-93568, 93571-93572, G0275, and G0278 diagnostic
0482-	Cardiology, Stress Test
0483-	Cardiology, Echocardiology
053X -	Osteopathic services
061X -	MRT
062X -	Medical/surgical supplies, incident to radiology or other diagnostic services
073X -	EKG/ECG
074X -	EEG
0918-	Testing- Behavioral Health
092X -	Other diagnostic services

 

This automated issue will be looking at outpatient hospital claim data and the beneficiary’s claim history for any inpatient admissions and their corresponding date of service that is included in Part A payments.

RAC issues for the week of October 28 – November 1, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner

·         Annual Wellness Visit (AWV) – JL - Annual Wellness Visit (AWV) G0438 (initial visit) billed more than once in a lifetime.

·         Evaluation and Management Per Diem Codes, Excess Units – JL - Initial hospital care and subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician.

Outpatient Hospital

·         Pre-admission Services – JL - Diagnostic and non-diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital, within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.

October 22, 2013

Drill Down – Observation Care Admission and Discharge Same Date

 RAC Region A contractor Performant posted an automated review on October 14, 2013 for Physician/Non-Physician Practitioners regarding Observation Care Admission and Discharge Same Date. The states impacted are Connecticut and New York.

Per the audit issue description, when a patient receives observation care for a minimum of 8 hours, but less than 24 hours, and is discharged on the same calendar date, observation care services (including admission and discharge services) should be reported with CPT code 99234, 99235 or 99236. The initial observation care or observation discharge CPT codes 99217, 99218, 99219 and 99220 should not be reported.

The issue references the Medicare Claims Processing Manual – CMS 100-04, Chapter 12, Section 30.6.8:

Observation services ordered for patients that present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.

In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.

The CPT code utilization is defined in this Section of the Medicare Claim Processing Manual. Since this is an automated review type, the contractor will be looking at claims data along with discharge times and dates.

RAC issues for the week of October 21 – October 25, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner

·         Observation Care Admission and Discharge Same Date – JK - When a patient receives observation care for a minimum of 8 hours, but less than 24 hours, and is discharged on the same calendar date, observation care services (including admission and discharge services) should be reported with CPT code 99234, 99235 or 99236. The initial observation care or observation discharge CPT codes 99217, 99218, 99219 and 99220 should not be reported.

October 15, 2013

Drill Down – Overutilization of Positive Airway Pressure (PAP) and Respiratory Assist Device (RAD) Accessories

 Last week RAC Region D contractor HDI posted an approved audit issue for DME – Physician providers for overutilization of Positive Airway Pressure (PAP) and Respiratory Assist Device (RAD) accessories. Per the contractor’s issue description, utilization is listed in the Positive Airway Assist (PAP) and Respiratory Assist (RAD) devices Local Coverage Determination (LCD) policies.  There is a common table that represents the usual maximum amount of accessories expected to be medically necessary. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not medically necessary.

Accessories used for positive airway pressure devices have maximum amounts per month and their utilization can be found in in the Durable Medical Equipment (DME) Local Coverage Determination (LCD) policies Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L171) and Respiratory Assist Devices (L11493).

ACCESSORIES:

The following table represents the usual maximum amount of accessories expected to be reasonable and necessary: 

A4604	1 per 3 months
A7027	1 per 3 months
A7028	2 per 1 month
A7029	2 per 1 month
A7030	1 per 3 months
A7031	1 per 1 month
A7032	2 per 1 month
A7033	2 per 1 month
A7034	1 per 3 months
A7035	1 per 6 months
A7036	1 per 6 months
A7037	1 per 3 months
A7038	2 per 1 month
A7039	1 per 6 months
A7046	1 per 6 months

 

Billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, will be denied as not reasonable and necessary. 

I have written before stressing the importance of knowing your LCDs since most automated RAC issues reference these polices where code combinations for medical necessity and utilization are spelled out. However, deciphering an LCD policy is not easy and may be a time consuming task. Building system edits for billing and practice management software could also get complicated. Most providers turn to software vendors to do this for them. Vendors will keep up with the numerous monthly changes in LCDs that may occur. Vendors can build edits such as alerts for providers to obtain signed ABNs for non-covered items, avoid overutilization and bill with allowed CPT/HCPCS/ICD combinations. Complex edits can also check for patient billing history to avoid providing services or dispensing items that are only covered on certain time frames. For example the PAP and RAD accessory HCPCS code A7046 that can only be billed every 6 months.

Web-based look-up tools from vendors allow for medical necessity checks to be done quickly and before a patient encounter or item is dispensed. Entering a code combination and finding out if those are listed in an LCD can be done in seconds rather than spending time trying to locate the correct policy on CMS’ website.

RAC issues for the week of October 14 – October 18, 2013:

RAC Region A Performant

Outpatient Hospital

§  Once-per-day Procedure Codes - JK - Potential incorrect billing occurred for claims billed with CPT/HCPCS codes listed in Appendix E more than once per day, per beneficiary, per provider.

October 7, 2013

Drill Down – Surgical Management of Morbid Obesity

 RAC Region C contractor Connolly has posted a complex audit review regarding medical necessity for the surgical management of morbid obesity for Inpatient Hospital and Physician providers. Connolly will be looking for overpayments that occurred when a non-covered procedure is reimbursed due to non-necessity. For Inpatient Hospital providers, the contractor will also review for DRG Validation which 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.

Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. The surgical management for the treatment of morbid obesity is considered reasonable and necessary only if the patient meets the definition of morbid obesity which is defined as a body mass index >= 35 and comorbid conditions exist as outlined in the National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) which are defined by ICD-9 codes.

The issue references not only the NCD/LCDs but also the Centers for Medicare & Medicaid Services (CMS) publications such as 100-04, Medicare Claims Processing Manual, Chapter 32, Section 150 - Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity, where the general coverage is listed as follows:

Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. The patient must have a body-mass index (BMI) 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be performed at an approved facility.

·         Open Roux-en-Y gastric bypass (RYGBP).

·         Laparoscopic Roux-en-Y gastric bypass (RYGBP).

·         Laparoscopic adjustable gastric banding (LAGB).

·         Open biliopancreatic diversion with duodenal switch (BPD/DS).

·         Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS).

·         Laparoscopic sleeve gastrectomy. (Effective June 27, 2012, covered at contractor’s discretion.)

RAC issues for the week of October 7 – October 11, 2013:

RAC Region A Performant

Outpatient Hospital

§  Pre-admission Services - JK (CT and NY) - Diagnostic and non-diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital, within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.

 RAC Region C Connolly

Inpatient Hospital

§  Surgical Management of Morbid Obesity -Medical Necessity - Inpatient (C003292013) - Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. The surgical management for the treatment of morbid obesity is considered reasonable and necessary only if the patient meets the definition of morbid obesity which is defined as a body mass index >= 35 and comorbid conditions exist as outlined in the National Coverage Determination and Local Coverage Determinations which are defined by ICD-9 codes. Overpayments exist when a non-covered procedure is reimbursed. The RAC will also review for DRG Validation which 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.

Physician

§  Surgical Management of Morbid Obesity - Medical Necessity Review - Carrier (C003282013) - Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. The surgical management for the treatment of morbid obesity is considered reasonable and necessary only if the patient meets the definition of morbid obesity which is defined as a body mass index >= 35 and comorbid conditions exist as outlined in the National Coverage Determination and Local Coverage Determinations which are defined by ICD-9 codes. Overpayments exist when a non-covered procedure is reimbursed.

RAC Region D HDI

DME Non-Physician

§  Complex Medical Review of Lower Limb Prosthetics - HDI will be doing a complex medical review of the Lower Limb Prosthetics reviewing the following: lower limb prosthetics within the previous five years, physician order, physician and prosthetics documentation, proof of delivery, and options and accessories related to the prosthetic(s).

§  Overutilization of Positive Airway Pressure (PAP) and Respiratory Assist Device (RAD) accessories per Physician - In the Positive Airway Assist (PAP) and Respiratory Assist (RAD) devices LCDs, there is a common table that represents the usual maximum amount of accessories expected to be medically necessary. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not medically necessary.