Drill Down: Continuous Passive Motion Devices

By
Original story posted on: September 23, 2013

alert-powered-by-decision-health

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

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

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

RAC Region B CGI

Inpatient

  • Other Vascular Procedures with MCC MS-DRG 252 (Medical Necessity Excluded) - MS-DRG validation requires that diagnostic and procedural information, present on admission indicator and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewer will validate for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG were met per Medicare guidelines.

RAC Region D HDI

DME/Non-Physician

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

Inpatient Acute Care Hospital

  • Incorrect Pt Status - Acute Underpayments - Acute hospitals have billed incorrect discharge statuses when a patient is transferred to another facility. The reimbursement for the acute hospital was underpaid based on the type of facility the patient was subsequently transferred to or the absence of any subsequent facility claim.
  • Pre-payment Review of MSDRG 391 - Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MSDRG 391, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.

Inpatient Rehab Facility

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

Outpatient Hospital

  • Excessive Units of Total Mastectomy - J1 - CPT codes for Total Mastectomy services are allowed only once per breast.
  • Excessive Units of Endovascular Revascularization of the Femoral/Popliteal Territory - J5 and Legacy - Only one code within the range of 37220-37235 should be reported for endovascular revascularization for each extremity vessel treated. The entire femoral/popliteal territory in one lower extremity is considered a single vessel for CPT reporting specifically for the endovascular lower extremity revascularization codes 37224-37227. Therefore, CPT codes in this range may only be reported once per lower extremity.
  • Excessive Units of Endovascular Revascularization of the Femoral/Popliteal Territory - Only one code within the range of 37220-37235 should be reported for endovascular revascularization for each extremity vessel treated. The entire femoral/popliteal territory in one lower extremity is considered a single vessel for CPT reporting specifically for the endovascular lower extremity revascularization codes 37224-37227. Therefore, CPT codes in this range may only be reported once per lower extremity.

Skilled Nursing Facility

  • Multiple 14 day assessments billed during a SNF stay - J1 (OIG) - The “14 day” Medicare MDS Assessment Type authorizes coverage and payment for a maximum of 16 days.
  • Excessive Units SNF 90 day assessment - J1 - The “90 day” Medicare MDS Assessment Type authorizes coverage and payment for a maximum of 10 days.
  • Excessive Units SNF 5 day assessment - The “5 day” Medicare MDS Assessment Type authorizes coverage and payment for a maximum of 14 days.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

Contact the Author

Margaret.Klasa@context4.com

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

Margaret Klasa, DC, APN, Bc

This email address is being protected from spambots. You need JavaScript enabled to view it.