December 14, 2011

RAC Regions A, D Post Issues

By

k-long

 

alert-powered-by-decision-health

 

 

 

 

 

 

 

HealthDataInsights, the RAC for Region D, posted five issues for inpatient hospitals last week. HDI cited CMS’s Medicare Benefit Policy Manual chapter one (Inpatient Hospital Services Covered Under Part A) and chapter six (Hospital Services Covered Under Part B) as document sources for all of the issues.

For RAC Region A, CGI posted one professional services about medically unlikely edits. For more, see the list below.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization – upper limb and toe amputation for circulatory system disorders without CC/MCC (DRG 257)

12/2/11

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, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – amputation for circulatory system disorders except upper limb and toe without CC/MCC (DRG 241)

12/2/11

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, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – other hepatobiliary or pancreas O.R. procedures with MCC (DRG 423)

12/2/11

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, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – thyroid, parathyroid and thyroglossal procedures with CC (DRG 626)

12/2/11

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, 6; CMS Pub. 100-08 chapter 6

Acute inpatient hospitalization – thyroid, parathyroid and thyroglossal procedures with MCC (DRG 625)

12/2/11

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, 6; CMS Pub. 100-08 chapter 6


 

Professional services

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Failure to correctly bill codes on the medically unlikely edit list for practitioner services

12/7/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Certain codes on the MUE list are being incorrectly billed. An error was made in billing these codes because more units were billed for same date of service for the same beneficiary by the same provider than what is medically likely and an appropriate modifier was not appended to the claim line.

National Correct Coding Policy Manual chapter 1; National Correct Coding Initiative Medically Unlikely Edits; CMS Pub. 100-08 chapter 3; CMS Pub. 100-20 Transmittal 617

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

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