Drill Down: Polysomnography Reported with Incorrect Diagnosis

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Original story posted on: March 24, 2014

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RAC Region B contractor CGI posted an automated review issue that was approved on March 6, 2014, for Outpatient providers targeting overpayments for polysomnography procedures when reported with the incorrect diagnosis.

Per the contractor’s description of this audit issue, polysomnography, the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of recording with physician review, interpretation and report, may be performed within the Critical Access Hospital setting.

This automated review will deny services reported with an incorrect diagnosis. The issue references CGS Administrator’s Local Coverage Determination (LCD) policies for the states of Kentucky and Ohio. The LCD policies list the specific CPT and ICD combinations allowed. The issue also references the Office of Inspector General (OIG) report titled Questionable Billing for Polysomnography Services that was published in October 2013 and the Centers for Medicare & Medicaid Services (CMS) publication 100-02 Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 70 - Sleep Disorder Clinics.

RAC Issues for the Week of March 24 – March 28, 2014:

RAC Region B CGI

Outpatient

  • CAH Polysomnography Services Correct Coding J15 CGS - Polysomnography, the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of recording with physician review, interpretation and report, may be performed within the Critical Access Hospital setting. This automated review will deny services reported with an incorrect diagnosis.

Professional

  • PF Observation Care Billed with Discharge Services on Same Day - J6 (NGS) - An issue exists where discharge services have been reported incorrectly with Observation Services on the same date of service. This automated review will identify the incorrect reporting of discharge services when billed on the same day as an Observation Service for a beneficiary.

  • PF Observation Care Billed with Discharge Services on the Same Day - J15 (CGS) - An issue exists where discharge services have been reported incorrectly with Observation Services on the same date of service. This automated review will identify the incorrect reporting of discharge services when billed on the same day as an Observation Service for a beneficiary.

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

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Margaret Klasa, DC, APN, Bc

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