An issue posted for complex review by the Region C recovery auditor (RAC) Connolly is similar to one in the Office of Inspector General (OIG) Work Plan for 2012.
The issue relates to multi-dose vials of Herceptin (Trastuzumab), which contain 440mg of the drug. Outpatient hospitals should bill only the doses of the drug administered to the patient, not any drug waste, Connolly noted.
The OIG issue does not specify provider type but does say the multi-use vials "are not subject to payment for discarded amounts of a drug or biological," the 2012 Work Plan stated.
The other issues Connolly posted Oct. 13 were automated reviews involving outpatient claims billed during inpatient stays, payments for noncovered mammography screenings or diagnostics and Bevacizumab injections for noncovered diagnoses.
For durable medical equipment (DME) suppliers, one issue was posted about inappropriate billing of spring-powered devices. For ambulance and transport services, Connolly posted one issue about billing claims during inpatient stays.
See below for more detail.
Outpatient Hospital
Name of issue | Date posted or approved | Regions/states where it is active | Description of issue | Document sources |
Outpatient claims billed within a PPS inpatient admission | 10/13/11 | RAC Region C | The reimbursement of outpatient services within a PPS Hospital stay is considered a duplicate payment in the Medicare Claims Processing Manual. This reimbursement would be an overpayment for services that were previously processed and paid. | CMS Pub. 100-04 chapters 1, 3, 18 |
Inappropriate screening/ diagnostic mammography payments | 10/13/11 | RAC Region C | Local coverage determination policy has indicated specific conditions or diagnoses that are covered for screening (77057, G0202) and diagnostic (77051, 77055, 77056, G0204, G0206) mammography services. Outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies. | CMS Pub. 100-04 chapter 18; national coverage determination NCD 220.4; TrailBlazer LCD L26764; First Coast LCDs L29328, L29329; Palmetto LCD L31785; Pinnacle Guide for Coding/Billing for Diagnostic and Screening Mammography; First Coast Guide on Diagnostic and Screening Mammography |
Multi-dose vial waste: Trastuzumab (Herceptin), J9355 | 10/13/11 | RAC Region C | Per its package label, Trastuzumab/Herceptin (J9355: INJECTION, TRASTUZUMAB, 10 MG) is supplied from the manufacturer in a 440mg multi-dose vial. Providers should be billing only units of J9355 associated with the amount of the drug administered to the patient. Drug waste is not paid and should not be billed for drugs supplied in multi-dose vials. | CMS Pub. 100-04 chapter 17; CDC FAQs regarding safe practices for medical injections; MLN Matters articles MM5718, MM6323, MM5520; CMS Q&A answer ID 8523; Trastuzumab/Herceptin full prescribing information; U.S. BLA Supplement: Herceptin |
Bevacizumab - noncovered diagnosis | 10/13/11 | RAC Region C | Local coverage determination policy has indicated specific conditions or diagnoses that are covered for Bevacizumab injections. Bevacizumab outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies. | Cahaba LCD L29992; Avastin treatment information for healthcare professionals; TrailBlazer LCD L26746 |
DME
Name of issue | Date posted or approved | Regions/states where it is active | Description of issue | Document sources |
Inappropriate billing of spring-powered device (A4258) | 10/13/11 | DME suppliers who bill CIGNA (RAC Region C) | More than one spring-powered device (A4258) per six months is not considered medically necessary. | CIGNA LCD L11520, CGS LCD L11520 |
Ambulance
Name of issue | Date posted or approved | Regions/states where it is active | Description of issue | Document sources |
Ambulance/ transport services provided during an inpatient hospitalization | 10/13/11 | RAC Region C | Ambulance transports provided by hospital-based ambulance suppliers to beneficiaries who are in an inpatient stay are the responsibility of the inpatient hospital provider with the exception of transports on the day of admission, day of discharge and during a leave of absence from the inpatient facility. | CMS Pub. 100-02 chapter 10; CMS Pub. 100-04 chapters 3, 15; Electronic Code of Federal Regulations Title 42, part 410, subpart B; OIG report A-01-04-00513; CMS Transmittal 668 from Sept. 2, 2005; Social Security Act section 1862 |
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.
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