October 10, 2011

3 DME, 1 Outpatient Hospital Issue Posted by RACs

By

k-long

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In a relatively quiet week for the RACs, three durable medical equipment issues and one outpatient hospital issue were posted.

The DME issues, posted by the RAC in regions B and C, tackle pharmacy dispensing and osteogenesis stimulators and overuse of PAP/RAD accessories.

For more details, see below.

Outpatient hospital

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Leuprolide 3.75mg incorrect code reported

 

9/26/11

RAC Region B

The purpose of the complex review is to identify the incorrect use of HCPCS code and corresponding number of units billed for services of Leuprolide (depot suspension) 3.75mg. An overpayment exists when a provider bills for greater than 3 units of service for HCPCS code J1950, as defined by applicable Local Coverage Determination documents.

CMS Pub. 100-02 chapter 15; National Government Services LCD L26369; Wisconsin Physicians Services Insurance Corporation LCD L30479

Pharmacy supply dispensing fee

10/5/11

RAC Region B

Medicare pays pharmacy supply/dispensing fees for immunosuppressive, oral anti-cancer, chemotherapeutic, and oral anti-emetic drugs as well as drugs used as part of an anti-cancer chemotherapeutic regimen when they are submitted on the same claim as the drug being billed. A claim submitted with a pharmacy supply/dispensing fee in the absence of any of the previously mentioned drugs represents an overpayment and will be denied as not medically reasonable and necessary.

Social Security Act Section 1842(o)(2); Title 42 CFR Part 447; CMS Pub. 100-04 chapter 17; CMS Transmittal 754; NGS LCDs L27005, L27036, L27127, L27226; NGS policy articles A47058, A47233, A47234, A47235; CMS Medlearn Matters Article #MM3990

Osteogenesis stimulators

9/29/11

DME suppliers who bill CIGNA Government Services

An overpayment exists when a provider bills for an osteogenesis stimulator with an ICD-9 code that is not included in the list of covered ICD-9 codes within the applicable Local Coverage Determination documents.

CIGNA LCD L5012

Overuse of PAP/RAD accessories 9/29/11 DME suppliers who bill CIGNA Government Services

A supplier must not dispense more than a certain quantity of PAP/RAD accessories at a time. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary.

CGS LCDs L11518, L5023

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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Karen Long

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