Drill Down: Portable and Stationary Oxygen Systems

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Original story posted on: July 1, 2013

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RAC Region A contractor Performant is targeting Durable Medical Equipment (DME) suppliers this week with regard to portable oxygen and stationary oxygenators. 

Claims for portable oxygen systems (HCPCS codes E0431, E0433, E0434, E1392, and K0738) will be denied when billed with stationary oxygen systems (HCPCS codes E0424, E0439, E1390, and E1391) that are paid at a higher allowance for a flow-rate greater than four liters per minute as indicated in the Oxygen and Oxygen Equipment Local Coverage Determination (LCD) and article.

Per coverage information, payment for stationary equipment is increased for beneficiaries requiring greater than four liters per minute of oxygen flow and decreased for beneficiaries requiring less than one liter per minute. If a beneficiary qualifies for additional payment for greater than four liters per minute of oxygen and also meets the requirements for portable oxygen, payment will be made for the stationary system at the higher allowance, but not for the portable system. In this situation, if both a stationary system and a portable system are billed for the same rental month, the portable oxygen system will be denied as not separately payable. 

Performant will be conducting an automated review of DME claims paid for both types of equipment in the same month when only one equipment type should have been paid at a higher allowance. 

RAC issues for the week of July1-5, 2013:

RAC Region A (Performant)     

DME Supplier Claim Types

  • Portable Oxygen System Paid with Stationary Oxygen System Allowed for a Flow Rate Greater Than 4 Liters per Minute (LPM) - Jurisdiction A - Claims for portable oxygen systems (HCPCS codes E0431, E0433, E0434, E1392, and K0738) will be denied when billed with stationary oxygen systems (HCPCS codes E0424, E0439, E1390, E1391) that are paid at a higher allowance for a flow rate greater than 4 liters per minute (LPM), as indicated in NHICs' Local Coverage Determination (LCD) L11468 and related Article A33768.

RAC Region B (CGI)

Inpatient Claim Types

  • Post-Acute Transfer - NGS - The purpose of this automated review is to identify patient discharge status codes improperly reported under Medicare’s Inpatient Prospective Payment System (IPPS) Transfer Policy. This policy applies to all DRGs using the patient discharge status code 02, and specified DRGs using patient discharge status codes 03, 05, 06, 62, 63, and 65. Under the transfer policy, the initial acute care facility shall be paid a per diem rate (up to the full DRG) and the receiving facility shall be paid the full DRG payment. Claims reported as discharge status 01 (to home) rather than as a transfer or claims reported as a transfer reported incorrectly would result in improper payment.        

Outpatient Hospital Claim Types

  • Outpatient Hospital Annual Wellness Visit Reported on SAME Day More than Allowed - NGS - The Annual Wellness Visit (AWV), either Initial or Subsequent, are only allowed to be reported no more than once per year per beneficiary. There are instances where professional and institutional claims are submitted for the AWV on the same date of service resulting in an overpayment of services.

RAC Region C (Connolly)           

Physician Claim Types

  • Blepharoplasty - Eyelid Lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.
  • Intensity-Modulated Radiation Therapy (IMRT) - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.

RAC Region D (HDI)         

Professional Services (Physician/Non-Physician Practitioner) Claim Types

  • Intensity-Modulated Radiation Therapy (IMRT) - Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific and often temporally modulated beams of radiation to solid tumors within a patient. IMRT is only covered for certain diagnosis and when certain conditions are met.
  • Blepharoplasty - Eyelid Lifts - Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will be denied.

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

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Margaret Klasa, DC, APN, Bc

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