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Unsurprisingly, after the Obama administration pledged additional funding for 2012 fraud and abuse detection efforts, utilization and specialty audits have soared throughout the U.S.

Physicians are receiving letters citing "Section 1842 (a)(1)(c) of the SSA requiring carriers under contract to the Centers for Medicare & Medicaid Services (CMS) to conduct audits to ensure that Medicare claims are being paid correctly." Most of the letters are focusing on evaluation and management services (new/established levels 4 and 5) and hospital admissions (levels 2 and 3). The MACs suggest that the audits are "educational," assisting both providers and carriers with proper submission of codes and accurate payments. Contrary to this, most of my clients have found the post-payment requests quickly graduate to pre-payment status. How soon the RACs will start participating within this new wave of focused audits remains unknown, as the data is highly suspect.

Much like the automated process for RAC contractors, the most recent wave of audits started with probe reviews using specialty peer groups and claims paid to compare providers and focus on the top 10 percent of amounts.

If providers are within that top 10 percent, a post-payment probe review is issued to start the process of "fishing" for potential overpayments based on documentation and medical necessity. Letters are mandating a 30-day window in which to provide necessity documents to substantiate types of service and levels of codes, based on 1995 or 1997 CMS documentation criteria.

There are a few interesting twists to these audits. Remember, MACs can and do communicate with other federal agencies and contracted auditors to share information that may be pertinent to other types of focused audits. For example, one of my clients in the Pacific Northwest received a probe audit letter in July 2011 for being one of the top 10 percent internists (within the state) billing 99214 (based on both volume and allowed charges). Following records submission, approximately 20 days later, a report was issued by the MAC with a demand letter citing "overpayment" for more than half of the audited dates of service. Furthermore, it was found that five out of 30 services were performed by a different provider (PA), who billed under the physician's NPI. The audit extended to the issue of "incident-to" billing along with the proving the CPT level. (Note: If you look at the 2012 OIG Work Plan, incident-to billing happens to be one the new issue areas for government agencies to probe, as this is clearly an area of high billing errors.)

The provider paid the overpayment and hired an outside consultant to review the CMS findings. In the meantime, the provider was issued a second, pre-payment letter for all 99214 services referencing the "Progressive Corrective Action Guidelines" established by CMS. Understand that this correspondence came directly from CMS, not the MAC, and was signed by a new auditor.  Fast forward to December and CMS continued to pend claims until documentation was received by the MAC, requesting all "incident-to" charges billed back to 2007.

Now it's January, and the evaluation and management review portion of the case has been elevated to a second appeal and recently was disputed in a legal hearing. Despite testimony about an independent review conducted by a consultant hired by the health system, the judge was highly focused on the number of follow-up visits for management of chronic problems, along with defining "moderate" and "high" levels of decision-making as outlined by the CMS documentation guidelines. The "incident-to" portion of the audit remains under review.

In a similar instance, another provider in a different state received the same post-payment audit notice. The reviewer found that, based on the area of the hospital, codes were billed incorrectly, as the issue was tied to a unit dedicated to skilled nursing services. Ironically, the second reviewer, CMS (not the MAC) has requested 30 new patient charts going back to 2007. Although HDI has not sent correspondence, it appears based on requested service dates that the provider will comply with the request. This provider is independent (not employed by a hospital or health system) and employs two NPs.

There are several lessons learned from these providers' experiences:

  • When CMS sends a letter requesting a "probe" on certain services, assume that they are looking at all aspects of coding and billing.
  • Internal audits for professional services are essential to ensure that services are coded and billed appropriately.
  • Place of service is significant for assigning the proper category of CPT service. RVUs and reimbursement can differ significantly based on where service is provided.
  • Medical necessity ultimately should drive level of service. Relying on encoders and electronic health record algorithms may not provide 100 percent accuracy. Judges are becoming increasingly critical on documentation points and the means used for determining correlation between "reason for visit" and assessment and plan.
  • Bell curve analyses of E/M codes may not provide an accurate picture of charge vulnerabilities. Consideration should be made to demographics, specialty and patient population.
  • Mid-level scope of service and billing limitations should be researched and communicated to providers and billing personnel.
  • Clinics operating under a provider-based status should research billing regulations when both a mid-level and a physician are providing professional services. The Medicare manuals have several areas where "incident-to" services are outlined, yet how they apply in a provider-based setting is quite variable. The first provider case above happens to be "solo," indicating a contracted provider with a health system, and is deemed "provider based" by contractual terms.
  • Small and "solo" doesn't equate to less vulnerability with regard to government audits.

 

Finally, bookmark the RAC contractor issue list for your state to analyze potential areas of risk when MACs or other CMS agencies order audits of professional services.

About the Author

Jana B. Gill, MA, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services.

Contact the Author

jana.gill@gillcompliance.com

To comment on this article please go to editor@racmonitor.com

The Dos and Don’ts for Proper Attending Physician Documentation to Ensure Medical Necessity Compliance

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DCS Healthcare has changed how it posts issues from listing individual MS-DRGs to major diagnostic categories (MDCs).

Providers should note that each category includes several MS-DRGs that the Region A recovery auditor (RAC) will review. For example, MDC 5 (diseases and disorders of the circulatory system) lists eight MS-DRGs, including MS-DRG 239 (amputation for circulatory system disorders except upper limb and toe with major complications and comorbidities) and MS-DRG 298 (cardiac arrest, unexplained without complications and comorbidities or major complications and comorbidities).

The Region A recovery auditor (RAC), which posted issues for 24 major diagnostic categories, did not respond to a request asking why they made the changes.

Connolly, the Region C RAC, posted two issues.

CLICK TO DOWNLOAD RAC ISSUES

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

To comment on this article please go to editor@racmonitor.com

In today's audit landscape, hospitals' inpatient short-stay claims are receiving increased attention from the Centers for Medicare & Medicaid Services (CMS). On Nov. 15, 2011, CMS announced the launch of two demonstration programs that directly impact hospitals, specifically as it pertains to these claims. The first such program, called the Part A-to-Part B Rebilling Demonstration Program, is voluntary. The second program, the Recovery Auditor Pre-Payment Review Demonstration Program, however, is mandatory for providers in 11 states.[2] Whether included in either of these programs or not, hospitals must be aware of the most current audit developments affecting them and effective strategies to employ during the audit appeals process.

AB Rebilling Demonstration Program

The Part A-to-Part B Rebilling Demonstration Program reflects CMS's stated goal to reduce improper payments from the Medicare program, and it will involve the participation of up to 380 hospitals.[3] The program's participants, determined through a first-come, first-serve application process, will consist of 80 large hospitals (300 or more beds), 120 moderate-sized hospitals (100-299 beds) and 180 small hospitals (99 or fewer beds).[4] The program will run for three years, from Jan. 1, 2012 to Dec. 31, 2014. Enrollment for the program opened at 2 p.m. EST on Dec. 12, 2011.

The AB Rebilling Demonstration Program only will involve the rebilling of certain claims for Part B reimbursement. Specifically, it will center on short-stay inpatient claims (denied on or after Jan. 1, 2012) that are denied by a Medicare Administrative Contractor, a Zone Program Integrity Contractor, a Recovery Auditor or Comprehensive Error Rate Testing (CERT) when services are determined to have been provided in an incorrect setting. Under the program, these claims can be resubmitted as new claims for outpatient services provided. In addition, short-stay inpatient claims self-identified by a provider as being rendered in the incorrect setting after services were provided and billed may be resubmitted as new claims for outpatient services.[5]

Under the program, once a hospital rebills a claim for Part B reimbursement it will receive 90 percent of the total Part B payment (not including observation services), but still will be required to refund the difference of the beneficiary's co-pay and deductible due under Part A and Part B.[6] CMS expressed its rationale for the 90 percent provision during its Nov. 30, 2011 Special Open Door Forum. The agency noted that it did not want to provide 100 percent of Part B reimbursement because it did not want to incentivize inaccurate billing, fearing that full payment would encourage hospitals to "game" the system.

One of the most concerning aspects of the AB Rebilling Demonstration Program is the requirement that participants waive their right to appeal all inpatient short-stay claims denied for lack of medical necessity when services are determined to have been provided in an inappropriate setting.[7] This highlights the inequity of a system in which a provider must choose between either appealing the denial of an inpatient claim and being unable to rebill the claim for outpatient reimbursement or rebilling the claim for 90 percent reimbursement of the Part B outpatient portion, yet waiving all due process rights.

Recovery Audit Pre-Payment Review Demonstration Program

Again, unlike the AB Rebilling Demonstration Program, the Pre-Payment Review Demonstration Program is mandatory and will have a dramatic effect on providers in the 11 participating states because it allows Recovery Auditors (RACs) to conduct pre-payment reviews on providers' Medicare claims.

In states outside of the demonstration program, RACs only may conduct post-payment reviews of providers' Medicare claims. However, on Dec. 30, 2011 CMS announced that the implementation of the Recovery Audit Pre-Payment Review Demonstration Program was being delayed until further notice. There has been no indication that this delay will be indefinite, therefore it is still important for providers to understand the basics of the program.

The Recovery Audit Pre-Payment Review Demonstration Program will allow RACs to review claims before they are paid to ensure that providers are complying with all Medicare payment rules.[8] The 11 states CMS selected for the demonstration program included Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri. Under the current plan CMS will roll out the demonstration program with a focus on inpatient short-stay claims, focusing on MS-DRG 312 Syncope & Collapse as the only claim initially subject to review. However as the program progresses, CMS will initiate pre-payment review of seven more DRGs. CMS likely will add even more claims, including physician claims, as the demonstration program proceeds. Furthermore, the program is being introduced in addition to, and not in replacement of, the current RAC Program. The limit on the number of medical records eligible to be reviewed by the contractors is the same as that which exists under the post-payment RAC program; therefore, the limits may be doubled for hospitals in the demonstration states.

Despite CMS's focus on the positives of the Recovery Audit Pre-Payment Review Demonstration Program, there are very serious implications for providers subject to its provisions.

Specifically, the program highlights the difficulty in balancing Medicare program integrity with the detrimental effects a pre-payment review has on Medicare providers. Pre-payment review is an aggressive and effective method for contractors to audit providers and prevent improper payments.  This method threatens providers, however, because it significantly impacts cash flow, and there are no substantive criteria or procedures in place to determine placement on (or removal from) pre-payment review lists. For hospitals in the demonstration program, they will have no choice but to experience pre-payment review and the possible devastating impacts it may have on their finances.


 

The looming implementation of CMS's Recovery Audit Pre-Payment Review Demonstration Program indicates a pronounced shift in contractors' focus on pre-payment reviews. From a Medicare program integrity perspective, a "prevent and detect" approach is an effective way to avoid improper payments, but pre-payment reviews can be unjustly devastating to providers. Specifically with regard to hospitals, pre-payment reviews may involve providers being forced to absorb the costs of expensive procedures and admissions while a contractor reviews (and potentially denies) a claim. In fact, if a hospital appeals a denied claim 30 days after each level of appeal, it could take at least a year before the claim reaches the ALJ level of appeal.[1]

One possible result of the Recovery Audit Pre-Payment Review Demonstration Program will be hospitals choosing to bill services they consider inpatient as outpatient services instead. Although hospitals should determine how to bill services based upon clinical decisions, this review demonstration program places them in a difficult position because of the uncertainty of payment for inpatient short-stay claims.

The Rest of Us

Even providers not participating in the recently announced CMS demonstration programs will be affected by the demonstration programs' implications on obtaining orders for Part B reimbursement for Part A denials for lack of medical necessity.

Specifically, the demonstration programs reinforce the importance that hospitals appeal Part A denials - and in the event that those claims continue to be denied, seek Part B reimbursement. In addition, the Recovery Audit Pre-Payment Review Demonstration Program highlights the importance that providers receive Part B reimbursement early in the process and do not have to wait until they reach the ALJ stage of appeal. At this juncture there is not an effective mechanism for providers not taking part in the Part A-to-Part B Rebilling Demonstration program to achieve Part B reimbursement in this context despite the fact that they are entitled to it by law.

Since the reimbursement mechanism is not in place, it is essential that hospitals continue to appeal Part A claims denied due to medical necessity when services allegedly are provided in the wrong setting - and, in the alternative, to seek Part B reimbursement. A consistent effort by the healthcare industry will help to encourage CMS to implement a mechanism for Part B reimbursement that not only reaches beyond the rebilling demonstration program, but also maintains hospitals' due-process rights to appeal Part A inpatient denials.

The demonstration programs announced late last year reflect the current state of the Medicare program and the federal government's extensive efforts to curb improper payments to providers.  However, they also reflect the need for hospitals to individually and collectively seek Part B reimbursement in the context of Part A claims denied for medical necessity.

About the Authors

Andrew B. Wachler is the principal of Wachler & Associates, P.C.  He graduated Cum Laude from the University of Michigan in 1974 and was the recipient of the William J. Branstom Award. He graduated Cum Laude from Wayne State University Law School in 1978. Mr. Wachler has been practicing healthcare and business law for over 25 years and has been defending Medicare and other third party payor audits since 1980.  Mr. Wachler counsels healthcare providers and organizations nationwide in a variety of legal matters.  He writes and speaks nationally to professional organizations and other entities on a variety of healthcare legal topics.

Jessica Lange is an associate at Wachler & Associates, P.C.  Ms. Lange dedicates a considerable portion of her practice to defending healthcare providers and suppliers in the defense of RAC, Medicare, Medicaid and third party payer audits.  Her practice also includes the representation of clients in Stark, anti-kickback, and fraud and abuse matters.

Contact the Authors

awachler@wachler.com

jlange@wachler.com

References:


[1] Interestingly, hospitals subject to the pre-payment review demonstration program that also are enrolled in the Part A-to-Part B Rebilling Demonstration Program will not be able to appeal pre-payment review denials of inpatient short-stay claims, but only will be able to rebill them through the Part A-to-Part B Rebilling Demonstration Program.

[2] The Recovery Audit Pre-Payment Review Demonstration Program's implementation was delayed on Dec.30, 2011.

[3] Part A to Part B Rebilling Demonstration Program, Provider Outreach and Education PowerPoint presentation, Nov. 28, 2011, available at: https://www.cms.gov/CERT/downloads/Rebilling_Demo_Outreach_1129.pdf (Last visited: Dec. 9, 2011).

[4] Id.

[5] Supra, Note 13. During the Special Open Door Forums, CMS clearly stated that conditional Code 44 still applies, wherein a hospital is precluded from changing the service from inpatient to outpatient once the patient has been discharged but when services have not yet been billed. This places hospitals in the demonstration program in a difficult position, because in order to rebill the short-stay inpatient services as outpatient they first must submit a bill for the inpatient services.

[6] Supra, Note 9.

[7] Supra, Note 13.

[8] Centers for Medicare & Medicaid Services, Fact Sheet for the Recovery Audit Pre-Payment Review Demonstration Program, Nov. 15, 2011, available at: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4170 (Last visited: Dec. 11, 2011).

The outpatient observation generally is ordered when physicians require time to complete the evaluation of an ED patient to determine the need for admission - or to complete simple treatment that can be rendered within in 24 hours - but it also may be ordered following outpatient surgery when the normal recovery period has to be extended for the management of minor complications.

"Normal" recovery times vary depending on the nature of the surgery. While the Medicare Benefit Policy Manual mentions four to six hours as "a guideline for normal recovery," the manual further indicates that "observation is appropriate when recovery exceeds normal expectations for the type of surgery, and when the patient's condition requires observation." Because of this (obviously, recovery for a simple mastectomy is going to be quite different from recovery for an inguinal herniorrhaphy), it is not really possible to define a true "normal" recovery period without considering the type of surgery performed and other factors.

Practices Vary

Surgeons' practices vary. One surgeon may keep a patient overnight following a certain type of surgery, while another may release his patients the same day for that surgery. It would not be appropriate for a surgeon to order observation for patients kept overnight for uncomplicated recovery, however. Even when common post-op care for a particular operation is labeled "overnight recovery," the duration of the stay alone does not determine the necessity for observation.

Medicare regulations go on to suggest when a patient's condition requires observation.  Observation is "restricted to situations where a patient exhibits an uncommon or unusual reaction to a surgical procedure ...and the condition requires monitoring and treatment beyond the treatment customarily provided in the immediate post-operative period."   Examples given in the regulations are drug reactions, difficulty awakening from anesthesia or "other post-surgical complication."

Other indicators for post-op observation recognized by Medicare QIOs include post-op bleeding, uncontrolled pain, uncontrolled nausea and vomiting, urinary retention, arrhythmias, psychotic reactions and electrolyte imbalance. More serious complications, of course, would justify inpatient admission per the usual admission criteria.

Medical Necessity

Medical necessity for observation is determined by the patient's clinical condition after a procedure and whether his or her recovery deviates from what would be expected for that procedure. For instance, observation can be ordered after four hours of recovery if a patient generally is expected to be ready for release directly from the recovery room within four hours, but has to be kept for additional treatment due to one of the conditions mentioned above or some other unexpected event such as chest pain or fever. If, however, the surgeon's routine post-op orders are for recovery beyond six hours, observation would not be appropriate unless some acute event occurs during that recovery period. When a patient's post-op stay exceeds the expected recovery time, it is appropriate to evaluate for the presence of a condition that would justify the ordering of observation services.

A physician also cannot order observation while the patient is in the OR, or immediately upon arrival to the PACU. It is only when the patient's post-op recovery is complicated, when there is an "unusual and unexpected event" deviating from normal recovery, that observation can be ordered. There has to be a specific outcome or event that is a clear departure from normal recovery for observation to be ordered.

Limitations of Use of Observation

An order for observation cannot be based on an assessment of the risk of complications or out of concern that the patient may have a difficult post-op course. In these cases, the surgeon may order extended monitoring in recovery and then order observation or admission (depending on the severity of the problem) if an unexpected event actually occurs.


There are other limitations on the use of observation. Observation cannot be ordered in the following circumstances:

  1. For uncomplicated outpatient testing or procedures. These patients are registered under outpatient status and cannot be placed in observation even if they occupy a bed prior to the procedure.
  2. Prior to an outpatient procedure. An order for post-procedure observation only can be written after the procedure and only if there is an unexpected outcome or event, including an exacerbation of a condition - never before the procedure is performed.
  3. For prep prior to an outpatient procedure, including medical clearance, bowel prep, hydration or the administration of medication to reduce the risk of complications.  These services may be performed in a hospital (if hospital policies allow), but the patient would be in outpatient status, without an order for observation.
  4. During routine recovery. Since the recovery period is included in the hospital's reimbursement for the procedure and the guideline for normal recovery is "four to six hours," an order for observation should not be written prior to completion of at least four hours of recovery. Recovery can be longer than six hours, but not shorter than four.
  5. For the convenience of the patient, physician or hospital.
  6. In place of a medically necessary inpatient admission or for a type of surgery that appears on the inpatient list.

The Medicare Benefit Policy Manual (Chapter 6) lists observation as "a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment and reassessment before a decision can be made regarding whether a patient will require further treatment as hospital inpatients or if they are able to be discharged from the hospital."

A patient in observation is an outpatient with an order for observation services. An "outpatient in a bed" is an outpatient occupying a hospital bed but not receiving observation services. They are both outpatients. The difference between the two is whether observation is indicated and has been ordered.

A hospital does not get any additional reimbursement for observation of a patient who has outpatient surgery (status indicator "T," Addendum B) the same day or the day before. Hospital reimbursement for the procedure (the APC) includes recovery and observation. CMS requires the hospital to report observation hours when ordered, but there is no direct reimbursement. While the use of observation for surgical patients has a negligible impact on a hospital's finances, again, reporting it is a regulatory requirement.

In summary, observation can be ordered for patients having outpatient surgery only if there is a post-operative clinical problem or a minor complication - not for preps or for routine recovery. Patients at risk of complications may qualify for admission for the procedure.

About the Author

Steven J. Meyerson, MD, is a Vice President of Accretive Physician Advisory Services®. He is Board Certified in Internal Medicine and Geriatrics. He has recently been the medical director of care management and a compliance leader of a large multi hospital system in Florida. He has distinguished himself by creating innovative service lines and managing education for Accretive PAS®.

Contact the Author

SMeyerson@accretivehealth.com

To comment on this article please go to editor@racmonitor.com

CMS Updates its Electronic Submission of Medical Documentation

 

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Personal care services have been under scrutiny recently with several fraud cases and a recent Office of Inspector General report asking New Jersey to pay back $145 million in claims that did not meet federal or state requirements.

In the December 2011 report, OIG said that 36 of the 100 sample claims did not meet at least one requirement including prior authorization, nursing supervision and personal care assistants receiving in-service education. Fourteen claims had more than one deficiency, the report stated]

For its part, New Jersey’s program, which defines personal care services as household chores and some health-related duties, disagreed with OIG’s findings.

Personal Care Services Charges for Others

In other states, attorneys general have filed criminal charges against people allegedly involved with personal care services fraud.

In North Carolina, 10 people were charged with submitting fraudulent timesheets for personal care services worth more than $59,000, the attorney general stated Dec. 19. Three others were charged with billing Medicaid $376,000 for personal care services that were not provided.

In Missouri, a woman was charged with six felony counts of Medicaid fraud for allegedly submitting claims for personal care services that she did not provide, the state’s attorney general said Dec. 6.

In Louisiana, a woman was charged with 13 counts of Medicaid fraud for filing claims for services, such as bathing and cooking, at times that the patient was receiving treatment at a hospital, the state’s attorney general said Oct. 25.

While RACs have not posted personal care services issues, contractors could be on the lookout in this potentially vulnerable area.

Inpatient RAC issues posted

RAC Region A posted 15 inpatient hospital issues last week ranging from an MS-DRG for other injury, poisoning and toxic effect diagnosis with major complications and comorbidities to an MS-DRG for hip and femur procedures except major joints with complications and comorbidities.

CLICK TO DOWNLOAD RAC ISSUES

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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Connolly, the Region C recovery auditor, posted a durable medical equipment issue that could prove lucrative, if an Office of Inspector General report on the topic is any indication.

The RAC will look for incorrect payments for maintenance and servicing of capped rental DME, according to the issue approved Dec. 23. Payment for maintenance and service of that equipment "is included in the rental payments and should not be reimbursed separately," Connolly stated on its website.

In an August 2010 report, "A Review of Claims for Capped Rental Durable Medical Equipment," OIG found that from 2006 to 2008, Medicare "erroneously allowed" $2.2 million in payments on 31,939 claims for maintenance and service of beneficiary-rented equipment.

OIG also discovered that Medicare erroneously allowed almost $4.4 million for repairs for beneficiary-rented capped rental DME and almost $27 million for repair claims of beneficiary-owned DME that did not meet payment requirements, the report stated.

DME is certainly a provider type that has seen increased scrutiny and enforcement. Here are a few examples of DME fraud:

  • The former owner of a Houston DME company was sentenced in December to more than 12 years in prison after unlawfully receiving Medicaid beneficiaries' information and filing false claims with the Texas Medicaid program, according to the U.S. Attorney in southern Texas. A judge also ordered the former owner to pay more than $1.4 million back to Texas Medicaid.
  • A co-owner and manager of a McAllen, Texas, DME company were convicted in December of submitting fraudulent claims for power wheelchairs, according to the U.S. Attorney in southern Texas. They "falsified and forged" physician medical orders and reports and other documentation and told Medicaid that the patients received power wheelchairs when patients actually received less expensive scooters.
  • An Illinois man pleaded guilty in November to health care fraud and money laundering charges after he instructed DME company employees to obtain beneficiary information and "order as many products as possible" whether or not they were medically necessary, according to the U.S. Attorney in Rhode Island. He faces up to 33 years in prison and a fine of $760,000 and must forfeit about $2 million he received by defrauding Medicare.

3 RACs Post Issues

Along with the DME issue, Connolly posted an outpatient hospital issue. Region A RAC DCS Healthcare Services and Region D RAC HealthDataInsights also posted issues recently.

Durable medical equipment

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect payments for maintenance and servicing of capped rental DME

12/23/11

RAC Region C

Payment for maintenance and servicing of capped rental DME equipment is included in the rental payments and should not be reimbursed separately.

CGS Administrators' DMEPOS fee schedule categories website; OIG report OEI-07-08-00550; CMS Pub. 100-04, chapter 20

 

Outpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect modifiers billed with bilateral indicator 2

12/23/11

RAC Region C

Certain modifiers cannot be billed with bilateral surgery indicator 2 because the relative value units (RVUs) are already based on the procedure being performed as a bilateral procedure.

Cahaba's "How to Bill for Services with Bilateral Indicators" website; Palmetto's "Jurisdiction 1 Part B - CPT Modifier 50" website


Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 471, cervical spinal fusion with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 131, cranial/facial procedures with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 824, lymphoma-nonacute leukemia with other O.R. procedure with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 829, myeloproliferative disorders or poorly differentiated neoplasms with other O.R. procedure with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 745, D&C, conization, laparoscopy and tubal interruption without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 628, other endocrine, nutritional and metabolic O.R. procedures with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 625, thyroid, parathyroid and thyroglossal procedures with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 687, kidney and urinary tract neoplasms with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 744, D&C, conization, laparoscopy and tubal interruption with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 735, pelvic evisceration, radical hysterectomy and radical vulvectomy without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 659, kidney and ureter procedures and non-neoplasm with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 949, aftercare with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 615, adrenal and pituitary procedures without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 946, rehabilitation without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 915, allergic reactions with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 034, carotid artery stent procedures with MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 755, malignancy, female reproductive system with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 334, rectal resection without CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 760, menstrual and other female reproductive system disorders with CC/MCC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 881, depressive neuroses

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 593, skin ulcers with CC

12/29/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 130, major head and neck procedures without CC/MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 469, major joint replacement or re-attachment of lower extremity with MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 808, major hematologic-immunologic diagnosis except sickle cell crisis and coagulation with MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 904, skin grafts for injuries with CC/MCC

12/28/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

MS-DRG validation for MS-DRG 016 and 017, autologous bone marrow transplant (medical necessity excluded)

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

MS-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 the attending physician description and the information contained in the beneficiary's medical record.

ICD-9-CM Official Guidelines for Coding and Reporting; ICD-9-CM Addendums and Coding Clinics; OIG report OAI-12-88-01010; CMS Pub. 100-08, chapter 6

MS-DRG validation for MS-DRG 570, 571 and 572, skin debridement (medical necessity excluded)

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

MS-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 the attending physician description and the information contained in the beneficiary's medical record.

ICD-9-CM Official Guidelines for Coding and Reporting; ICD-9-CM Addendums and Coding Clinics; OIG report OAI-12-88-01010; CMS Pub. 100-08, chapter 6

Medical necessity review for MS-DRG 941, O.R. procedure with diagnoses of other contact with health services without CC/MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 029, spinal procedures with CC or spinal neurostimulatore

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 220, cardiac valve and other major cardiothoracic procedures without cardiac catheterization with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 326, stomach, esophageal and duodenal procedures with MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 496, local excision and removal internal fixation devices except hip and femur with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 746, vagina, cervix and vulva procedures with CC/MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 963, other multiple significant trauma with MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 535, fractures of hip and pelvis with MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 501, soft tissue procedures with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 835, acute leukemia without major O.R. procedure with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 342, appendectomy without complicated principal diagnosis with CC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 482, hip and femur procedures except major joint without CC/MCC

12/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 596, major skin disorders without MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 285, acute myocardial infarction, expired without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 508, major shoulder or elbow procedures without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 166, other respiratory system O.R. procedures with MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 951, other factors influencing health status

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 957, other O.R. procedures for multiple significant trauma with MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 132, cranial/facial procedures without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 405, pancreas, liver and shunt procedures with MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 443, disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 511, shoulder, elbow or forearm procedure, except major joint procedure with CC

12/19/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 644, endocrine disorders with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 217, cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 896, alcohol/drug abuse or dependence without rehabilitation therapy with MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 645 endocrine disorder without CC/MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 840, lymphoma and nonacute leukemia with MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 084, traumatic stupor and coma, coma greater than one hour without CC/MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 987, nonextensive O.R. procedure unrelated to principal diagnosis with MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 975, HIV with major related condition with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 655, major bladder procedures without CC/MCC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 935, nonextensive burns

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 740, uterine, adnexa procedures for non-ovarian adnexal malignancy with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 940, O.R. procedure with diagnoses of other contact with health services with CC

12/16/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-01000, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Acute inpatient hospitalization - amputation for musculoskeletal system and connective tissue disorders with CC (DRG 475)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - upper limb and toe amputation for circulatory system disorders with CC (DRG 256)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - craniotomy with major device implant/acute complex CNS PDX without MCC (DRG 024)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - revision of hip or knee replacement without CC/MCC (DRG 468)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - amputation for circulatory system disorders except upper limb and toe with CC (DRG 240)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - back and neck procedures except spinal fusion with CC/MCC or disc device/neurostim (DRG 490)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - craniotomy with major device implant/acute complex CNS PDX with MCC or chemo implant (DRG 023)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - cholesystectomy except by laparoscope without common duct exploration without CC/MCC (DRG 416)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - major head and neck procedures without CC/MCC (DRG 130)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - peripheral/cranial nerve and other nervous system procedures without CC/MCC (DRG 042)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - cranial/facial procedures without CC/MCC (DRG 132)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - cranial/facial procedures with CC/MCC (DRG 131)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - craniotomy and endovascular intracranial procedures without CC/MCC

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6


 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - craniotomy and endovascular intracranial procedures with MCC (DRG 025)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - peripheral/cranial nerve and other nervous system procedures with CC or peripheral neurostimulation (DRG 041)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - carotid artery stent procedure with MCC (DRG 034)

12/15/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08, chapter 6

 

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

To comment on this article please go to editor@racmonitor.com

When contemplating my latest article for RACmonitor.com, I originally planned to perform a review of physician issues being reviewed by the RACs. As part of that process I thought I would take a look at the RAC Frequently Asked Questions (FAQs) on the CMS website to see if there have been any glaring changes to report. I found one omission so notable that my original article must wait for another day.

In the past, the following question and answer appeared under the RAC FAQs on the CMS website:

"Q: I received an additional documentation request (ADR) letter from a Recovery Audit Contractor (RAC) for an issue that is not approved on their website. Do I need to submit the record?

A: RACs may request a small sample of records to assist CMS in determining if an audit concept is consistent with Medicare policy and should be approved for widespread review. Providers must still submit the requested documentation to the RAC within the expected time frame to avoid having that claim denied. The RAC will complete its review of the claim and issue a review results letter within 60 days."

Much like Jimmy Hoffa, Amelia Earhart and the World Series hopes of the Chicago Cubs, this particular FAQ has disappeared.

On the surface, this would appear to be good news. A more reactionary reader might reach the conclusion that the RACs no longer are allowed to perform reviews outside the scope of the approved issues lists on their respective websites. As I discovered with a short investigation, that would be a knee-jerk - and possibly costly - mistake.

For the answer to this mystery, we have to return to the revised RAC Statement of Work released this past September. I direct your attention to Page 11 under bolded item No. 6 (why did I just get a flashback of the classic television show The Prisoner?) entitled "random selection of claims." According to this paragraph, the RACs are statutorily prohibited from selecting claims randomly for review for any purpose "other than to establish an error rate." The RACs must use data analytic techniques to conduct "targeted reviews." I can't speak for the reader, but the longer I look at those two sentences, the less able I am to reach any conclusion other than the fact that the disappearance of the FAQ listed above will have no meaningful effect on RAC operations going forward.

In order to determine that an issue should be added to an approved listing, a RAC has to first perform analytics, followed by establishing a reliable error rate. Truthfully, the only way the contractors can achieve this by their own volition is through the type of small claims sampling used to reach a determination for widespread approval, as was once described in The Incredible Disappearing FAQ.

The provider community, particularly in hospital settings, is doing its level best to keep up with changes and adjustments to government audit programs. In order to keep all of our heads above water, it is in the best interests of CMS to let us know not only when new issues appear under the RAC FAQs on its website, but also to let us know when things have been removed and why. CMS did not bother to do this in this particular case, but providers should know that, as far as RAC review types are concerned, nothing has changed.

For now, anyway...

About the Author

Paul Spencer is the Compliance Officer for Fi-Med Management, Inc., a national physician practice financial management company based in Wauwatosa, WI. Paul has over 20 years of experience across all facets of healthcare billing, including 6 years spent with insurance carriers. In his current role with Fi-Med, he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.

Contact the Author

pspencer@fimed.com

To comment on this article please go to editor@racmonitor.com

Addressing Homelessness Through Better Documentation

alert-powered-by-decision-health

 

Two hospitals have settled allegations of overcharging the government for infusion therapy and lithotripsy services, the U.S. Attorney for eastern California announced Dec. 7.

Sutter Health Association paid more than $1.4 million for the 25 northern California affiliate hospitals that were involved in the case, the U.S. Attorney stated.

Catholic Healthcare West paid more than $875,000 for the 36 affiliate hospitals in California, Nevada and Arizona that were involved in the case, the U.S. Attorney stated.

The Department of Health and Human Services' Office of Audit Services discovered the two health systems had duplicated charging for the administration of infusion therapy, unbundled infusion therapy services that should have been billed together and duplicated billing of lithotripsy services under separate revenue codes, the U.S. Attorney stated.

Another hospital, New Milford (Conn.) Hospital, had to pay almost $472,000 to resolve False Claims Act allegations involving improper billing for injections of leuprolide acetate, as previously reported in RAC Alert.

Region A RAC Posts 29 Issues

DCS, the Region A RAC, posted 29 inpatient issues Dec. 9 through Dec. 15. For more detail on the issues, see the list below.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 216, cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC

12/15/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 709, penis procedures with CC-MCC

12/15/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 834, acute leukemia without major O.R. procedure with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 825, lymphoma and nonacute leukemia with other O.R. procedure without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 433, cirrhosis and alcoholic hepatitis with CC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 455, combined anterior/posterior spinal fusion without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 025, craniotomy and endovascular intracranial procedures with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 585, breast biopsy, local excision and other breast procedures without CC-MCC

12/13/11

 

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 822, lymphoma and leukemia with major O.R. procedure without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 219, cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 822, lymphoma and leukemia with major O.R. procedure without CC-MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 219, cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 781, other antepartum diagnoses with medical complications

12/13/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 284, acute myocardial infarction, expired with CC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 444, disorders of the biliary tract with MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 199, pneumothorax with MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 024, craniotomy with major device implant/acute complex central nervous system principal diagnosis without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 407, pancreas, liver and shunt procedures without CC-MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 037, extracranial procedures with MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 462, bilateral or multiple major joint procedures of lower extremity without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 462, bilateral or multiple major joint procedures of lower extremity without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 032 ventricular shunt procedures with CC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 945, rehabilitation with CC-MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for MS-DRG 023, craniotomy with major device implant/acute complex central nervous system principal diagnosis with MCC or chemo implant

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 923, other injury poisoning toxic effect diagnosis without MCC

12/12/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 327, stomach, esophageal and duodenal procedures with CC

12/9/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 506, major thumb or joint procedures

12/9/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review for MS-DRG 442, disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC

12/9/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

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.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 

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

To comment on this article please go to editor@racmonitor.com

k-long

 

alert-powered-by-decision-health

 

 

 

 

 

 

 

HealthDataInsights, the RAC for Region D, posted five issues for inpatient hospitals last week. HDI cited CMS’s Medicare Benefit Policy Manual chapter one (Inpatient Hospital Services Covered Under Part A) and chapter six (Hospital Services Covered Under Part B) as document sources for all of the issues.

For RAC Region A, CGI posted one professional services about medically unlikely edits. For more, see the list below.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization – upper limb and toe amputation for circulatory system disorders without CC/MCC (DRG 257)

12/2/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – amputation for circulatory system disorders except upper limb and toe without CC/MCC (DRG 241)

12/2/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other hepatobiliary or pancreas O.R. procedures with MCC (DRG 423)

12/2/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – thyroid, parathyroid and thyroglossal procedures with CC (DRG 626)

12/2/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – thyroid, parathyroid and thyroglossal procedures with MCC (DRG 625)

12/2/11

RAC Region D

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6


 

Professional services

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Failure to correctly bill codes on the medically unlikely edit list for practitioner services

12/7/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Certain codes on the MUE list are being incorrectly billed. An error was made in billing these codes because more units were billed for same date of service for the same beneficiary by the same provider than what is medically likely and an appropriate modifier was not appended to the claim line.

National Correct Coding Policy Manual chapter 1; National Correct Coding Initiative Medically Unlikely Edits; CMS Pub. 100-08 chapter 3; CMS Pub. 100-20 Transmittal 617

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

To comment on this article please go to editor@racmonitor.com

Latest RAC Findings: Improper Inpatient Coding of Coronary Bypass Procedures

The OIG in 2012 will continue to address previous years' problem areas, but it currently appears to be taking a closer look into physician billing, specifically the use of modifiers that impact reimbursement.

In the 2011 Work Plan, the OIG identified that providers were billing evaluation and management services improperly during times of other global services. As defined in the CMS Claim Processing Manual, Chapter 12, Section 40.1, "global services" for most minor procedures have a term of 10 days, and for major procedures that term extends to 90 days. Services included within the global period are defined as:

  • Preoperative visits: such visits occur after the decision to operate is made, typically on the day before the day of surgery for major procedures and on the day of surgery for minor procedures;
  • Intra-operative services: services that are normally a usual and necessary part of a surgical procedure;
  • Complications following surgery: all additional medical or surgical services required during the postoperative period of surgery because of complications that do not require an additional trip to the operating room;
  • Postoperative visits: follow-up visits related to recovery from surgery;
  • Postsurgical pain management: services typically also performed by the surgeon;
  • Supplies: except for those identified as exclusions; and
  • Miscellaneous services: services such as dressing changes; local incisional care; removal of an operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary devices.

Carve-out Services

CMS also defines carve-out services that are excluded from global reimbursement; these include the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures, and the initial evaluation always is included in the allowance for a minor surgical procedure.

Such carve-out services also include the following:

  • Services of other physicians, except when the surgeon and the other physician(s) agree on the transfer of care. This agreement may be denoted in the form of a letter or an annotation in the discharge summary, hospital record or ASC record;
  • Visit(s) unrelated to the diagnosis for which the surgical procedure is performed (unless the visit(s) occur due to complications of surgery);
  • Treatment for an underlying condition or an added course of treatment that is not part of normal recovery from surgery;
  • Diagnostic tests and procedures, including diagnostic radiological procedures; and
  • Clearly distinct surgical procedures, performed during the postoperative period, that are not defined as re-operations or treatment for complications.

Evaluation & Management Services

"Evaluation & Management Services During Global Surgery Periods," the focus was directed toward the use of modifier -24 (unrelated evaluation and management service by the same physician during the global period). Per this section, if the modifier was appended to an evaluation and management services during the global period of another procedure, the claim would be paid in addition to global allowance. The diagnosis code also would be the "key" to inform CMS that the problem met the definition of "unrelated."

Another likely finding was E/M services coded without modifiers, billed and paid during the global period. This may have been a case when providers performing surgical services attempted to "break out" the pre- or postoperative care without understanding the basic CMS rules surrounding minor and major surgical services. The bottom line is this: if payment is made wrongfully by CMS, it becomes the responsibility of the provider to identify and remedy the incorrect payment before penalties are incurred.

As with many OIG audit targets, the scope of the review is broad and provides little direction with regard to interpretation. Several modifiers impact payment depending on the existence of complications, staged procedures and multiple providers.

As with automated reviews, RAC contractors can identify when separate providers bill for the same procedure without breaking down intraoperative and postoperative services. An example of this may be when a patient is seen in the emergency room for a displaced fracture and the physician performs a closed reduction, referring the patient to orthopedic for follow-up. If the orthopedic surgeon only manages post-operative care, the modifier -55 should be appended to the surgical CPT code, thus splitting the "global fee" and calculating only a percentage of the total RVU (relative value unit). Likewise, the ER provider only would bill for the surgical portion using the same CPT code with modifier -54 (surgical service only).


Modifiers 78 and 58

Another area of potential vulnerability exists when deciding whether a patient should return to the OR during the global period based on complications or undergo a more extensive procedural service. Modifiers -78 and -58 both provide a means of additional reimbursement depending on patient condition and, ultimately, documentation. The biggest difference between these modifiers is the RVU payment and the continuation of actual "global days."  Modifier -78 (return to the OR for a related procedure) only pays for the intraoperative portion of the global fee, whereas modifier -58 (staged or related procedure) pays the entire fee and starts a new global period.

Although many conclusions can be drawn based on diagnosis, these claims most likely would fall to a complex review to determine proper use of a modifier and thus percentage of payment. As a precautionary activity, to learn more about other modifiers that impact payment see the CMS Claim Processing Manual, Chapter 12, Section 40.2, along with the 2012 OIG Part B issue summaries.

About the Author

Jana B. Gill, MA, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services.

Contact the Author

jana.gill@gillcompliance.com

To comment on this article please go to editor@racmonitor.com

The Essential Requirements for Effective Utilization Review