Updated on: January 31, 2013

Inpatient Issues Dominate New Posts

By
Original story posted on: October 2, 2011

k-long

alert-powered-by-decision-health

 

 

 

 

 

 

 

 

RACs in Region A, B and D posted new issues this past week. But of note, Connolly, the Region C RAC, modified its list of issues to include a date posted and allow for sorting by issue name, issue type, claim type, state affected and date approved.

The new issues are below.

Part A

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review – MDC 6 diseases and disorders of the digestive system; MS-DRGs 347,348, 349, 350, 351, 352, 353, 354, 355, 356, 357, 358, 368, 369, 370, 371, 372, 373, 374, 375, 376, 377, 378, 379, 380, 381, 382, 383, 384, 385, 386, 387, 388, 389, 390, 391, 392, 393, 394, 395

9/27/11

Md.

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.

Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; PEPPER Reports; OIG reports A-01-10-01000, A03-00-00007, OAI-05-88-00730; Change request 3200, transmittal 156; admission of less than 24 hours policy – Maryland

Medical necessity: Acute inpatient admission respiratory conditions (collaborative); MS-DRGs 177-180, 190-198, 202-206

9/27/11

Md.

RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly.

RAC demonstration evaluation; CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 13; Section 1814(b)(3) of the Social Security Act; Change request 3200, transmittal 156; admissions of less than 24 hours policy – Maryland

Medical necessity review – MDC 5 conditions of the circulatory system (Medical); MS-DRGs 286, 287, 288, 289, 290, 291, 292, 293, 299, 300, 301, 302, 303, 304, 305, 308, 309, 310, 311, 312, 313, 314, 315, 316

9/19/11

Md.

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.

Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; PEPPER Reports; OIG reports A-01-10-01000, A03-00-00007, OAI-05-88-00730; Change request 3200, transmittal 156; MLN Article #MM3200; admission of less than 24 hours policy – Maryland

 

 

 

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity: Acute inpatient admission neurological disorders; MS-DRGs 068,069, 070, 071, 072, 073, 074, 103, 312 (collaborative)

9/27/11

Md.

RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 13; RAC demonstration evaluation; Section 1814(b)(3) of Social Security Act; Change request 3200, transmittal 156; admissions of less than 24 hours policy – Maryland

Acute inpatient hospitalization – infections, female reproductive system with MCC (DRG 757)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – malignancy, male reproductive system with MCC (DRG 722)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – endocrine disorders with CC (DRG 644)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – menstrual and other female reproductive system disorders without CC/MCC (DRG 761)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


 

Acute inpatient hospitalization – menstrual and other female reproductive system disorders with CC/MCC (DRG 760)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – infections, female reproductive system without CC/MCC (DRG 759)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – malignant breast disorders with MCC (DRG 597)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – skin ulcers without CC/MCC (DRG 594)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – skin ulcers with CC (DRG 593)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – diabetes without CC/MCC (DRG 639)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – trauma to the skin, subcutaneous tissue and breast with MCC (DRG 604)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


Acute inpatient hospitalization – malignant breast disorders with CC (DRG 598)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major cardiovascular procedures with MCC or thoracic aortic aneurysm repair (DRG 237)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major cardiovascular procedures without MCC (DRG 238)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – malignancy of hepatobiliary system or pancreas with MCC (DRG 435)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – viral meningitis with CC/MCC (DRG 075)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – viral meningitis without CC/MCC (DRG 076)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – coronary bypass without cardiac cath without MCC (DRG 236)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


DME by physician

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Excessive billing of positive airway pressure (PAP) and respiratory assist device (RAD) accessories

9/19/11

RAC Region B

Medicare allows payment of PAP and RAD accessories when coverage criteria for the devices have been met. However, the National Government Services Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L27230) state that when supplies are dispensed more frequently or in quantities of supplies greater than usual maximum amounts are dispensed, they will be denied as not medically reasonable and necessary.

Social Security Act, Volume 1, Title XVIII; CMS Pub. 100-04 chapter 20; CMS Pub. 100-08 chapter 4; National Government Services (NGS) LCD L27230; NGS Supplier Manual chapter 15; NGS Article A47228; NGS April 27, 2010, and May 10, 2010, webinar question-and-answer summary

Professional

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Verteporfin and ocular photodynamic therapy without fluorescein angiography

9/19/11

RAC Region B

The purpose of this audit is to identify overpayments associated with providers billing for Verteporfin (J3396) and Ocular Photodynamic Therapy (OPT) (67221-67225) in the absence of fluorescein angiography (92235) or indocyanine-green angiography (92240) performed prior to each treatment.

CMS Pub. 100-03 chapter 1; Wisconsin Physicians Services (WPS) Fluroescein Angiogram

Multiple dose allergy vials

9/19/11

RAC Region B

The purpose of this complex review is to ensure accurate reporting of CPT code 95165 (preparation and provision of antigens for allergen immunotherapy).

CMS Pub. 100-04 chapter 12; National Government Services; Palmetto LCD L6955; Wisconsin Physicians Services (WPS) immunotherapy

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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

Karen Long

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