August 13, 2013

Drill Down: Minor Surgery and Other Treatment Billed as Inpatient

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RAC Region A Performant posted a complex review issue this week regarding minor surgery and other treatment billed as an inpatient stay. Perfomant cites the Centers for Medicare & Medicaid (CMS) publication 100-02 – Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A, “Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital. In certain specific situations coverage of services on an inpatient or outpatient basis is determined by the following rules:

Minor Surgery or Other Treatment - When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.”

Claims that will be reviewed under this approved issue are for minor surgical procedures and treatments that are at risk of improper payment for inpatient care when outpatient care was provided; however, claims for patients admitted through the emergency department are excluded.

RAC issues for the week of August 12–August 16, 2013:

RAC Region A Performant

Psychiatric Facility (IPF) (Inpatient Psychiatric Hospital and Inpatient Psychiatric Unit)

  • Inpatient Psychiatric Hospital and Inpatient Psychiatric Unit Services (Medical Necessity Review of MDC 19: Mental Diseases and Disorders, and Medical Necessity Review of MDC 20: Alcohol/Drug and Alcohol/Drug-Induced Organic Mental Disorders) - Medicare pays for inpatient psychiatric hospital and inpatient psychiatric unit services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of: •MS-DRG 876 O.R. Procedure with Principal Diagnosis of Mental Illness •MS-DRG 880 Acute Adjustment Reaction and Psychosocial Dysfunction •MS-DRG 881 Depressive Neuroses •MS-DRG 882 Neuroses Except Depressive •MS-DRG 883 Disorders of Personality and Impulse Control •MS-DRG 884 Organic Disturbances and Mental Retardation •MS-DRG 885 Psychoses •MS-DRG 886 Behavioral and Developmental Disorders •MS-DRG 887 Other Mental Disorder Diagnoses •MS-DRG 894 Alcohol/Drug Abuse or Dependence, Left Against Medical Advice •MS-DRG 895 Alcohol/Drug Abuse or Dependence with Rehabilitation Therapy •MS-DRG 896 Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy with MCC •MS-DRG 897 Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy without MCC

Inpatient Hospital

  • Minor Surgery and Other Treatment Billed as an Inpatient Stay - IOM 100.02 Chapter 1, Section 10, states "Minor Surgery or Other Treatment - when patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came in to the hospital, whether they used a bed, and whether they remained in the hospital past midnight." Claims billed for minor surgical or other treatment are identified for medical record review based on risk of improper payment for inpatient care when outpatient care was provided. Claims for patients admitted through the emergency department are excluded. • PLEASE NOTE: DISREGARD THE STATEMENT IN THE “DATES OF SERVICE” SECTION BELOW. FOR THIS ISSUE, CLAIMS HAVING A “CLAIM PAID DATE” WHICH IS MORE THAN 2 YEARS PRIOR TO THE ADR DATE WILL BE EXCLUDED.

RAC Region B CGI

Comprehensive Outpatient Rehabilitation Facilities

  • Comprehensive Outpatient Rehabilitation Facilities Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Home Health

  • Home Health Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Inpatient

  • Minor Surgery and Other Treatment Billed as an Inpatient Stay (Medical Necessity) - IOM 100-02, Chapter 1, Section 10, states “Minor Surgery or Other Treatment – When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.” Claims billed for minor surgical or other treatment are identified for medical record review based on risk of improper payment for inpatient care when outpatient care was provided.

 

Outpatient Hospital

  • Outpatient Hospitals Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Outpatient Professional

  • Outpatient Professional Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Outpatient Rehabilitation Facility

  • Outpatient Rehabilitation Facilities Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

Skilled Nursing Facility

  • Skilled Nursing Facility Pre-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.

RAC Region D HDI

DME Non-Physician

  • No-Power Option Power Wheelchairs Incompatible With Any Power Seating System - Power seating systems may not be used with any Group 1 Power Wheelchairs and any Group 2, 3 or 4 Power Wheelchairs that are classified as ‘no power option’ wheelchairs.
  • Excessive Units of Diabetic Supplies - Lancets and Test Strips - LCD L196 limits the number of allowed units for HCPCS code A4259 (Lancets) and A4253 (Test Strips). Quantities that exceed the maximum allowance without evidence of physician evaluation within the prior six months are not considered reasonable and necessary.

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

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