September 11, 2011

Watch for Patient Control Numbers on Remittance Advice

By

k-long

alert-powered-by-decision-health

 
 

 

To ease payment posting, CMS has instructed intermediaries to include patient control numbers on remittance advice when reporting recoupment of overpayments.

The change, which CMS announced in Change Request 7499 on Aug. 5, applies to the Fiscal Intermediary Standard System (FISS), Multi-Carrier System (MCS) and Viable Information Processing Systems (VIPS). The patient control numbers will replace the Medicare health insurance claim number. The change is scheduled to be fully implemented by April 2, 2012.

New RAC postings

Connolly, the recovery auditor (RAC) for Region C, and HealthDataInsights, the RAC for Region D, posted several new issues in the past couple of weeks.

Carrier

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Infliximab (Remicade) billed with therapeutic injection/infusion

 

RAC Region C

Infliximab (Remicade) is a monoclonal antibody agent. Infusion administration should be billed as a chemotherapy and other highly complex drug or highly complex biologic agent infusion administration. Some providers will bill with therapeutic infusion administration.

CMS Pub. 100-04 chapter 12; Remicade Infliximab website at www.centocoraccessone.

com; Cahaba LCD L30613; Pinnacle LCD L8482; CIGNA LCD L9686

Intravenous immune globulin (IVIG) is billed with chemotherapy and highly complex drugs infusion administration

 

RAC Region C

Intravenous immune globulin (IVIG) infusion administration should be billed therapeutic infusion codes. Some providers will bill with chemotherapy and highly complex drug infusion administration codes.

Cahaba LCDs L30612, L30029; Pinnacle LCD L31189; Trailblazer LCDs L17361, L26774; First Coast LCD L29205; www.gammagardliquid.

com

 


 

Durable medical equipment

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Non-routine medical supplies and home health consolidated billing

 

RAC Region C

Under the prospective payment system, a home health agency must bill for all home health services, which include nursing and therapy services, except DME. DME was excluded from the Balanced Budget Act and the Balanced Budget Refinement Act established a consolidated billing requirement. The law requires that all home health services paid on a cost basis be included in the PPS rate. The PPS rate will include nursing and therapy services, routine and nonroutine medical supplies, home health aide and medical social services.

CMS Pub. 100-04 chapters 10, 20

Lower limb suction valve prosthetics

 

RAC Region C

Codes L5647 and L5652 describe a modification to a prosthetic socket that incorporates a suction valve in the design. The items described by these codes are not components of a suspension locking mechanism (L5671). L5647 and L5652 comprise a different mechanism for attaching the prosthetic. L5647 and L5652 cannot be billed for the same limb as L5671 on the same date of service.

CMS Pub. 100-02 chapter 15; CGS Administrators LCD L11442; CGS Administrators local coverage article A25528; CIGNA article A25528

Payments for DME provided to beneficiaries in skilled nursing facility (SNF) stays covered under Medicare Part A

 

RAC Region C

Payment for the majority of SNF services provided to beneficiaries in a Medicare covered Part A SNF stay are included in a bundled prospective payment made through the fiscal intermediary/Medicare administrative contractor to the SNF. These bundled services are to be billed by the SNF to the FI/MAC in a consolidated bill.

CMS Pub. 100-02 chapter 15; CMS Pub. 100-04 chapters 6, 20; OIG report A-01-05-00511

Coverage of a CPAP (positive airway pressure device)

 

RAC Region C

Coverage of a PAP (positive airway pressure) device for the treatment of OSA (obstructive sleep apnea) is limited to claims where the diagnosis of OSA is based upon a Medicare-covered sleep test

Medicare National Coverage Determinations Manual chapter 1; CIGNA LCD L11518;

 


 

Inpatient Hospital

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute readmission – No B4

 

RAC Region C

Same day readmission to the same facility for similar/same symptoms should be considered one stay and hospital should adjust to make the entire stay on one claim only.

OIG report A-03-01-00011; CMS MLN Matters #MM3389; 2004 CMS Change Request 3389

Post-acute transfer – underpayments

 

RAC Region C

Inpatient claims were identified with discharge disposition to an acute care inpatient facility (02), skilled nursing facility (03), home health (06), inpatient rehab facility (62), long-term care facility (63) or psychiatric facility (65). These inpatient claims fall under the post-acute transfer policy and are reimbursed on per diem rate, up to full MS-DRG reimbursement. However, there is no identified claim submission from a receiving facility.

ICD-9-CM Vol. 1, 2, 3 coding manuals (2007-2009); ICD-9-CM addendums and coding clinics (2007-2009); CMS Program Integrity Manual chapter 6.5.3

Hospital to hospital transfer

 

RAC Region C

Inpatient hospital incorrectly reports the patient is discharged to home when patient has been discharged to another facility (SNF, IRF, home health) or left against medical advice (and was later admitted to another facility on same day of discharge), which the inpatient hospital claim from the transferring facility fall under the post-acute transfer policy. According to that policy, transferring facility should be reimbursed on per-diem basis (up to DRG full payment) while the receiving facility receives the full DRG or respective PPS reimbursement. All DRGs being reviewed are available in post-acute transfer policy.

 

CMS Pub 100-04 chapter 3; 2004 CMS Change Request 2934; Aug. 22, 2007, Federal Register; Prospective Payment System for Inpatient Hospital Services

Medical necessity: Acute inpatient admission, MS-DRG 515

 

RAC Region C

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.

CMS Pub. 100-02 chapter 1; CMS Pub. 100-08 chapter 6; RAC Demonstration Program Evaluation of the Three-Year Demonstration; CMS Pub. 100-08 chapter 13

Medical necessity: Injury, poisoning toxic effects of drugs

 

RAC Region C

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 billed correctly for MS-DRGs 917, 918, 919, 920 and 921.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6, 13; RAC Program: Evaluation of the Three-Year Demonstration;

Medical necessity: Diseases & disorders of the kidney and urinary tract

 

RAC Region C

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 billed correctly for MS-DRGs 688, 698, 699 and 700.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6, 13; RAC Program: Evaluation of the Three-Year Demonstration;

Medical necessity: Diseases and disorders of the blood and blood-forming organs and immunological disorders

 

RAC Region C

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 billed correctly for MS-DRGs 814, 815 and 816.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6, 13; RAC Program: Evaluation of the Three-Year Demonstration;

Medical necessity: Endocrine, nutritional and metabolic diseases and disorders

 

RAC Region C

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 billed correctly for MS-DRGs 629 and 630.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6, 13; RAC Program: Evaluation of the Three-Year Demonstration;

Medical necessity – surgical cardiovascular procedures 224-227, 242-244, 245, 246-249, 250-251, 252-254, 258-259, 260-262, 263, 264, 265 (collaborative)

 

RAC Region C

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.

CMS Pub. 100-02 chapters 6, 11; CMS Pub. 100-04 chapter 4; CMS Pub. 100-08 chapters 6, 13; Social Security Act section 1886; OIG report 09-88-00880; OIG report A-03-00-00007; OIG report OAI-05-88-00730; OIG report A-01-10-01000; Inpatient Prospective Payment System Hospital and Long Term Care Hospital Review and Measurement Fact Sheet; Pepper Report

Medical necessity – diseases and disorders of the digestive system MS-DRG 347-349, 350-358, 368-369, 370-379, 380-389, 390-395 (collaborative)

 

RAC Region C

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.

CMS Pub. 100-02 chapters 6, 11; CMS Pub. 100-04 chapter 4; CMS Pub. 100-08 chapters 6, 13; Social Security Act section 1886; OIG report 09-88-00880; OIG report A-03-00-00007; OIG report OAI-05-88-00730; OIG report A-01-10-01000; Inpatient Prospective Payment System Hospital and Long Term Care Hospital Review and Measurement Fact Sheet; Pepper Report

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

 

RAC Region C

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.

CMS Pub. 100-02 chapters 6, 11; CMS Pub. 100-04 chapter 4; CMS Pub. 100-08 chapters 6, 13; Social Security Act section 1886; OIG report 09-88-00880; OIG report A-03-00-00007; OIG report OAI-05-88-00730; OIG report A-01-10-01000; Inpatient Prospective Payment System Hospital and Long Term Care Hospital Review and Measurement Fact Sheet; Pepper Report

Acute inpatient hospitalization – dental and oral diseases w/MCC (DRG 157)

9/2/11

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 ear, nose, mouth and throat diagnosis w/CXC (DRG 155)

9/2/11

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 – pulmonary embolism w/o MCC (DRG 176)

9/2/11

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 – pulmonary embolism w/MCC (DRG 175)

9/2/11

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 ear, nose, mouth and throat diagnoses w/MCC (DRG 154)

9/2/11

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 – spinal disorders and injuries without CC/MCC (DRG 053)

9/2/11

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 – spinal disorders and injuries with CC/MCC (DRG 052)

9/2/11

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 – nervous system neoplasms w/o MCC (DRG 055)

9/2/11

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 – nervous system neoplasms w/MCC (DRG 054)

9/2/11

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 – vaginal delivery w/o complicating diagnosis (DRG 775)

9/2/11

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 – vaginal delivery w/complicating diagnosis (DRG 774)

9/2/11

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 antepartum diagnoses w/medical complications (DRG 781)

9/2/11

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 – threatened abortion (DRG 778)

9/2/11

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 – malignancy, female reproductive system w/CC (DRG 755)

9/2/11

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 – malignancy, male reproductive system w/o CC/MCC (DRG 724)

9/2/11

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 – malignancy, male reproductive system w/CC (DRG 723)

9/2/11

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 – malignancy, female reproductive system w/MCC (DRG 754)

9/2/11

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 – benign prostatic hypertrophy w/MCC (DRG 725)

9/2/11

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 – sprains, strains and dislocations of hip, pelvis and thigh with CC/MCC (DRG 537)

8/19/11

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 – sprains, strains and dislocations of hip, pelvis and thigh w/o CC/MCC (DRG 538)

8/19/11

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

 


 

Other FI biller

 

Name of issue

Date posted or approved

Regions/states where it is active

400Description of issue

Document sources

Readmission to IPF (inpatient psychiatric facility)

 

RAC Region C

Patients who are readmitted to the IPF within three days of discharge are considered to have an interrupted stay. In such cases, Medicare treats the readmission as a continuation of the original stay with lengths of stay adjustments applied accordingly.

OIG Report A-01-09-00508; CMS Final Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS) Fact Sheet

 

Outpatient hospital

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Intravenous immune globulin (IVIG) is billed with chemotherapy and highly complex drugs infusion administration

 

RAC Region C

Intravenous immune globulin (IVIG) infusion administration should be billed therapeutic infusion administration codes. Some providers will bill with chemotherapy and highly complex drug infusion administration codes.

Cahaba LCD L30029; Pinnacle LCD L31097; Palmetto LCD L28275; Trailblazer LCD L26774; www.gammagardliquid

.com

 

Incorrect billing of J1642 – Heparin up to 10 units (Hep-Lock, Hep-Flush) – Hospital

 

RAC Region C

Claims identified where J1642 (Heparin up to 10 units [Hep-Lock, Hep-Flush]) was billed for patients who receive Heparin for therapeutic infusion. The therapeutic infusion of Herapin should be J1644 (Heparin, up to 1,000 units).

2010 Table of Drugs on www.cms.gov; Alpha-Numeric HCPCS website on www.cms.gov

Injection/infusion initial administration codes – excessive units billed

 

RAC Region C

Initial administration service codes for injections/infusions are to be billed once per patient per date of service.

CGS Administrators local coverage article A25528

Hyperbaric oxygen therapy (HBOT) – non-covered diagnosis or diagnoses

 

RAC Region C

HCPCS code C1300 is assigned for each unit of 30-minutes of HBOT. Per national coverage determination (NCD) and local coverage determinations (LCD), HBOT is covered for specific diagnoses. HBOT claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the NCD and LCD policies.

NCD for hyperbaric oxygen therapy (20.29); First Coast LCD L29192; Trailblazer LCD L26598; CMS Pub. 100-04 chapter 32; Article 4M-30AB-R2

ECGs with cardiac catheterization procedures

 

RAC Region C

An overpayment may exist when outpatient hospital providers bill separately for ECGs performed the same date of service as cardiac catheterization procedures. ECGs unrelated (e.g. performed prior to or after) the cardiac catheterization should be billed with modifier 59.

National Correct Coding Initiatives Edits on

www.cms.gov

Procedure billed without corresponding device code (outpatient hospital – ASC)

 

RAC Region C

Procedure-to-device edits require that when a particular procedural code is billed, the claim must also contain an appropriate device code

CMS MLN Matters #7443; Hospital Outpatient PPS website on www.cms.gov;

CMS Change

Request 7443

 

 

 

 


Physician

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Filgrastim (300 mcg) – Dose vs. units billed (medical necessity excluded)

 

RAC Region C

Filgrastim (J1440) represents 300 micrograms (mcg) per unit and should be billed 1 unit for every 300 mcg per patient per date of service

www.neupogen.com; CMS Pub. 100-04 chapter 17; CMS MLN Matters #MM5718

Evaluation and management services during global surgery periods

 

RAC Region C

Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure and related E&M services provided during the global surgery period. The global surgery fee includes payment for E&M services provided during the global surgery period.

CMS Pub. 100-04, chapter 12; OIG report A-05-06-00040

Evaluation and management with allergy services

 

RAC Region C

Identification of overpayments made for evaluation and management services billed without modifier 25 on the same date of service as allergy testing or allergy immunotherapy.

National Correct Coding Initiatives Edits website on www.cms.gov; CMS Pub. 100-04 chapter 12

Place of service errors for physician claims for service performed in hospital inpatient setting

 

RAC Region C

Federal regulations at 42 CFR 414.22(b)(5)(i)(B) provide for different levels of payments to physicians depending on where the services are performed. An improper payment exists when physicians bill services with the incorrect place of service other than hospital inpatient (POS 21).

None listed

Injection/infusion initial administration codes – excessive units billed

 

RAC Region C

Initial administration service codes for injections/infusions are to be billed once per patient per date of service.

CMS Pub. 100-04 chapter 4, 12; CMS MLN Matters #3818, #6349

Place of service errors for physician claims for service performed in an ASC or outpatient hospital

 

RAC Region C

Federal regulations at 42 CFR 414.22(b)(5)(i)(B) provide for different levels of payments to physicians depending on where services are performed. Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician’s office (POS 11) than it does when the service is performed in a hospital outpatient department (POS 22) or with certain exceptions in an ASC (POS 24). We will determine whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments.

OIG report A-01-09-00503; CMS Pub. 100-04 chapter 12; OIG report A-01-08-00528; OIG report A-05-04-00025

Anesthesia – CRNA overpaid

 

RAC Region C

Anesthesia provided by a certified registered nurse anesthetist and anesthesiologist without a 50% cutback as per Medicare guidelines involving CRNA’s supervised by anesthesiologists.

CMS Pub. 100-04 chapter 12; Code of Federal Regulations Title 42

Anesthesiologist overpaid

 

RAC Region C

Anesthesia provided by an anesthesiologist and a CRNA without a 50% cutback as required by Medicare guidelines involving anesthesiologists supervising CRNAs.

CMS Pub. 100-04 chapter 12; Code of Federal Regulations Title 42

 

 

 

 

 


 

Professional services

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Professional co-surgery

9/2/11

RAC Region B

Services are being billed separately that should be included in the Skilled Nursing Facility Consolidated billing. Consolidated Billing is when services provided during the resident's stay in a skilled nursing facility (SNF) are bundled into one package and billed by the Skilled Nursing Facility. Under the Consolidated Billing requirement, a Skilled Nursing Facility itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services).

CMS Pub. 100-04, chapters 12 and 23

Pulmonary diagnostic procedures and evaluation and management services

 

RAC Region C

Identification of overpayments associated with evaluation and management services (99211-99215) billed without modifier 25 on the same date of service as a pulmonary diagnostic procedure (94010-94799).

National Correct Coding Initiatives Edits website at www.cms.gov

 

 

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

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