November 19, 2013

Drill Down – Drugs and Biologics: Over/Underpayments

 

RAC Region D contractor HDI posted a review issue for Outpatient Hospital provider types regarding both excessive units billed and underpayments for Drugs and Biologics. I have previously written about maximum drug and biologics allowable units in my August 6^th, 2013 Drill Down article. This issue seems to continue to plaque providers in all RAC regions. You can link to my previous article here: http://racmonitor.com/rac-enews/1478-drill-down-maximum-allowable-units.html. Some overpayments may be discarded drug wastage that was billed incorrectly.

 

Per the contractor’s description of this issue:

 

Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed must accurately represent the dosage increment specified in the HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriately discarded drug wastage. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Billable drug wastage should be coded according to the requirements of the local contractor. Claims billed with medically unlikely billed units will be reviewed to determine the correct number of billable/payable units. Claims billed with units below the approved compendia diagnosis specific dosing guideline minimums will be reviewed to determine the correct number of billable/payable units.

The contractor references the CMS Pub-100-04 Claims Processing Manual Chapter 17, Section 40 for billing of discarded drugs and biologics:

 

40 - Discarded Drugs and Biologicals

 

The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.

 

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.
 

When processing claims for drugs and biologicals (except those provided under the Competitive Acquisition Program for Part B drugs and biologicals (CAP)), local contractors may require the use of the modifier JW to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological. For example, a single use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and 5 units discarded. The 95 unit dose is billed on one line, while the discarded 5 units may be billed on another line by using the JW modifier. Both line items would be processed for payment.

 

The JW modifier is only applied to the amount of drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. For example, one billing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.

The JW modifier is not used on claims for CAP drugs. For CAP drugs, see subsection 100.2.9 - Submission of Claims With the Modifier JW, “Drug or Biological Amount Discarded/Not Administered to Any Patient”, for additional discussion of the discarded remainder of a vial or other packaged drug or biological in the CAP.

 

NOTE: Multi-use vials are not subject to payment for discarded amounts of drug or biological.

 

I have previously written about maximum drug and biologics allowable units in my August 6^th, 2013 Drill Down article. This issue seems to continue to plaque providers in all RAC regions. You can link to my previous article here: http://racmonitor.com/rac-enews/1478-drill-down-maximum-allowable-units.html

 

RAC Issues for the Week of November 18 – November 22, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner

·         Mohs Micrographic Surgery (MMS) with Pathology Different Providers – JK - Mohs Micrographic Surgery (MMS) requires a single surgeon to act in two distinct roles: surgeon and pathologist. When the preparation and interpretation of the slides of tissue taken during the surgery are performed by someone other than the surgeon, then MMS may not be billed.

·         Mohs Micrographic Surgery (MMS) with Pathology Different Providers – JL - Mohs Micrographic Surgery (MMS) requires a single surgeon to act in two distinct roles: surgeon and pathologist. When the preparation and interpretation of the slides of tissue taken during the surgery are performed by someone other than the surgeon, then MMS may not be billed.

·         Observation Care Admission and Discharge Same Date – JL - 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.

RAC Region D HDI

Outpatient Hospital

·         Medically Unlikely Billed Doses of Drugs - Underpayment – Outpatient - Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code descriptor. The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate, discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Drug waste should be coded and documented according to the requirements of the local contractor. Claims billed with units below the approved compendia diagnosis specific dosing guideline minimums will be reviewed to determine the correct number of billable/payable units.

November 12, 2013

Drill Down – Evaluation and Management Per Diem Codes, Excess Units

 RAC Region A contractor Performant posted an automated review issue on November 5, 2013 for Physicians and Non-Physicians Practitioners provider types regarding Evaluation and Management Per Diem Codes, Excess Units. Per the contractor’s description of this issue, initial hospital care and subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician. The states that are affected in this region are DC, Delaware, Maryland, New Jersey, and Pennsylvania.

 The contractor references the CMS Pub-100-04 Claims Manual, Physician/Non-Physician Practitioner, Chapter 12, Section 30.6.9:

A. Hospital Visit and Critical Care on Same Day

When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.

Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

 Physicians and qualified non-physician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.

 

RAC issues for the week of November 11 – November 15, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner

·         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.

RAC Region D HDI

Outpatient Hospital

·         Excessive Units - Drugs and Biologics - Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed must accurately represent the dosage increment specified in the HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriately discarded drug wastage. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Billable drug wastage should be coded according to the requirements of the local contractor. Claims billed with medically unlikely billed units will be reviewed to determine the correct number of billable/payable units.

·         Trastuzumab (Herceptin) Multi-dose vial – Outpatient - 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, Section 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."

Professional Services (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, Section 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."

November 5, 2013

Drill Down – Major Joint Replacement

 

RAC Region C contractor Connolly posted a condition of coverage review for both Inpatient and Physician providers on October 23, 2013, regarding major joint replacement. The description posted on Connolly’s site describes the issue as:

 

“Major joint replacement is reserved for patients whose symptoms have not responded to other treatments. The goal of the surgery is to relieve pain and improve or increase patient function. Medical documentation will be reviewed to determine if the major joint replacement was reasonable and necessary for the patient.”

 

In a 2011 Comprehensive Error Rate Testing (CERT) report from the Centers for Medicare & Medicaid Services (CMS), major joint replacements were cited as follows: The services related to major joint replacements had an improper payment rate of 11.5 percent, accounting for 2.1 percent of the overall Medicare FFS improper payment rate. The projected improper payment amount for joint replacements during the 2011 report period was approximately $686.7 million.

 

As a result of the CERT report, CMS further requires sufficient documentation for major joint replacement.

 

One of the references Connolly sites for this issue is CMS’ MedLearn Matters article #SE1236, “Documenting Medical Necessity for Major Joint Replacement (Hip and Knee)”

The following document types often provide the information needed to support the medical necessity of a total joint replacement, but are frequently missing from the submitted record. This list is not exhaustive it is a sample.

 

 History:

•        Description of the pain (onset, duration, character, aggravating, and relieving factors);

•        Limitation of Activities of Daily Living (ADLs) – specify;

•        Safety issues (e.g. falls);

•        Contraindications to non-surgical treatments;

•        Listing and description of failed non-surgical treatments such as:

-   Trial of medications (e.g. NSAIDs);

-   Weight loss;

-   Physical therapy;

-   Intra-articular injections;

-   Braces, orthotics or assistive devices

  

Physical Examination:

•        Deformity;

•        Range of motion;

•        Crepitus;

•        Effusions;

•        Tenderness;

•        Gait description

 

Investigations

Results of applicable investigations (e.g. plain radiographs). Document the findings

 

Clinical Judgment:

•        Reasons for deviating from a stepped-care approach

  

Example of Documentation Demonstrating Medical Necessity for Joint Replacement

Surgery

 

A. The hospital record for the preoperative joint replacement surgical patient includes:

 

History:

·         Present illness from onset until the present;

·         Current symptoms and functional limitations;

·         Outcomes of nonsurgical treatments, such as;

-   Medications e.g., Anti-inflammatory medication, Analgesics;

-   Intra-articular injections;

-   Physical Therapy and/or home exercise plans;

-   Assistive devices e.g., cane, walker, braces (specify type of brace), orthotics;

·         Comorbidities.

 

Physical Examination:

·         Joint examination with detailed objective findings.

 

Investigations:

·         Preoperative imaging studies.

 

The hospital record for the joint replacement surgical patient includes documentation

of specific conditions. For example:

 

·         Osteoarthritis (mild, moderate, severe);

·         Inflammatory arthritis (e.g., rheumatoid arthritis, psoriatic arthritis);

·         Failure of previous osteotomy;

·         Malignancy of distal femur, proximal tibia, knee joint, soft tissues;

·         Failure of previous unicompartmental knee replacement;

·         Avascular necrosis of knee;

·         Malignancy of the pelvis or proximal femur or soft tissues of the hip;

·         Avascular necrosis of the femoral head;

·         Fractures (e.g., distal femur, femoral neck, acetabulum);

·         Nonunion, malunion, or failure of previous hip fracture surgery; and

·         Osteonecrosis.

 

B. The hospital record for the postoperative joint replacement surgical patient includes:

 

·         Operative report for the procedure, including observed pathology;

·         Daily progress notes for inpatients; and

·         Discharge plan and discharge orders.

  

Example of a medical record that may result in a DENIED claim

Mrs. Smith is a female, age 70, with chronic right knee pain. She states she is unable to walk without pain and pain meds do not work. Therefore, she needs a total right knee replacement.

 

 

Example of a medical record with more detail and support of medical necessity

 

History:

Mrs. Smith is a 70-year-old female who is suffering from end-stage Osteoarthritis (OA) of her right knee, worsening gradually over the past 10 years. Treatment has included NSAIDs which have not effectively relieved her pain/inflammation and which have recently begun to cause her gastric distress. She has also participated in an exercise program/physical therapy for the past 3 months without functional improvement. Sometimes the pain keeps her awake at night. She is using a cane and is no longer able to climb the five steps to her front door. Personal safety is compromised as she had falls x 3 in attempting the stairs to her home entrance. Her knee pain and stiffness limit her ability to perform ADLs. She cannot walk from her bedroom to her kitchen without stopping to rest.

 

Physical Examination:

Vital Signs: 140/90, Heart rate 78, RR 18.

Physical exam: Bilateral varus knee deformity consistent with severe osteoarthritis. Right knee extension reduced to minus 15 degrees and flexion to less than 100 degrees. Unable to rise from chair unassisted. Full motion of the right hip, no calf tenderness or ankle edema. Antalgic gait noted.

 

Investigations:

X-ray (7/2/11): right knee shows joint space narrowing along with marginal osteophytes.

 

Impression:

Total Knee Arthroplasty (TKA) indicated.

 

Plan/Orders:

Discussed risks and benefits of total joint replacement with patient. Patient understands both.

Admit to inpatient care for right TKA. Forward a copy of this note to include in patients chart along with a copy of the patient’s x-ray reports.

 

 

RAC issues for the week of November 4 – November 8, 2013:

RAC Region C Connolly

Inpatient

·         Medical Necessity - Condition of Coverage Review: Major Joint Replacement - IP - C004072013 - Major joint replacement is reserved for patients whose symptoms have not responded to other treatments. The goal of the surgery is to relieve pain and improve or increase patient function. Medical documentation will be reviewed to determine if the major joint replacement was reasonable and necessary for the patient.

 

Physician

·         Medical Necessity - Condition of Coverage Review: Major Joint Replacement - Carrier - C004092013 - Major joint replacement is reserved for patients whose symptoms have not responded to other treatments. The goal of the surgery is to relieve pain and improve or increase patient function. Medical documentation will be reviewed to determine if the major joint replacement was reasonable and necessary for the patient.