November 12, 2013

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

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

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

A. Hospital Visit and Critical Care on Same Day

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

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

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

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

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

RAC Region A Performant

Physician/Non-Physician Practitioner

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

RAC Region D HDI

Outpatient Hospital

  • Excessive Units - Drugs and Biologics - Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed must accurately represent the dosage increment specified in the HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriately discarded drug wastage. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Billable drug wastage should be coded according to the requirements of the local contractor. Claims billed with medically unlikely billed units will be reviewed to determine the correct number of billable/payable units.
  • Trastuzumab (Herceptin) Multi-dose vial – Outpatient - Per its Package Label, Trastuzumab (Herceptin) is supplied by the manufacturer in a 440 mg multi-dose vial. Per Medicare Claims Processing Manual (100-04) Chapter 17, Section 40: "When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label...Note: Multi-use vials are not subject to payment for discarded amounts of drug or biological."

Professional Services (Physician/Non-Physician Practitioner)

  • Trastuzumab (Herceptin), Multi-dose vial waste - Per its Package Label, Trastuzumab (Herceptin) is supplied by the manufacturer in a 440 mg multi-dose vial. Per Medicare Claims Processing Manual (100-04) Chapter 17, Section 40: "When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label...Note: Multi-use vials are not subject to payment for discarded amounts of drug or biological."

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 payers.

Contact the Author

Margaret.Klasa@context4.com

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

Margaret Klasa, DC, APN, Bc

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