Health Information Management

RACs continue to post new CMS-approved audit issues

HIM-HIPAA Insider, December 29, 2009

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DCS Healthcare, Connolly Healthcare, and HealthDataInsights (HDI), the RACs for regions A, C, and D, respectively, continue to post newly approved issues on their Web sites.
 
Connolly Healthcare has added the following new issue for outpatient hospital claims submitted by providers in all region C states:
  • Medically unlikely edit (MUE) list. An MUE applies to all HCPCS/CPT codes that are above the maximum units of service that a provider would report for the same beneficiary, on same date of service, and same provider. An error was made in billing these services because more units were billed for a beneficiary than what is medically likely.
DCS Healthcare also added a new RAC issue this week for providers in the following states: Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont. According to the DCS Healthcare Web site, the new issue pertains to Clinical Social Worker (CSW) services. Its description is as follows:
  • CSW services. CSW services rendered during an inpatient acute care or skilled nursing facility stay are not separately payable under Medicare Part B; instead they are included in the facility’s Prospective Payment System payment. CSW providers are expected to render services under arrangement with the facility. Therefore, an issue may exist when a beneficiary received CSW services during an inpatient stay, which have been billed and reimbursed under Medicare Part B.
DCS also added the following six new issues for DME claim review in all region A states:
  • Wheel attachment with new non-wheeled walker. Wheel attachment (E0155) cannot be paid on the same day or within one month of the initial issue of a non-wheeled walker. Therefore, an issue may exist when a beneficiary receives this wheel attachment, which has been billed and reimbursed under Medicare Part B, within a month of an initial issue of a non-wheeled walker.
  • Headrest with a power operated vehicle or a power wheelchair with a captain’s chair seat. Headrests (E0955) may not be billed the same date of service as a power operated vehicle (POV) or power wheelchair (PWC) with a captain’s chair seat. Therefore, an issue may exist when a beneficiary receives a POV or PWC with a captain’s chair seat and a headrest, which has been billed and reimbursed under Medicare Part B on the same date of service.
  • Multiple DME rentals within a month. Certain procedure codes may not be billed in conjunction with other procedure codes for the same date of service and for the same beneficiary. Therefore an issue may exist when these codes are billed and reimbursed under Medicare Part B on the same date of service and for the same beneficiary.
  • Prosthetic additions with initial or preparatory knee prosthesis. When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510–L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment, except for certain codes. Therefore, an issue may exist when these codes are billed and reimbursed under Medicare Part B with such prosthesis.
  • Lower limb suction value prosthesis. Codes L5647 and L5652 incorporates a suction valve in its design, therefore separate payment is not allowed for code L5671 which was created to specifically to address suspension sockets using mechanical locking mechanisms. This code was not meant to be an “add on” for suction suspension. Therefore, an issue may exist when such a locking mechanism is billed and reimbursed under Medicare Part B along with a suction valve suspension.
  • Solid insert with seat or back wheelchair cushions. Code E0992 (solid seat insert) is not separately payable when provided with a seat or a seat back wheelchair cushion. Therefore an issue may exist when E0992 is billed and reimbursed under Medicare Part B with a seat or seat back wheelchair cushion.
In addition, HDI has added three new RAC issues for all states in Region D. According to the HDI Web site, the new issues are as follows:
  • Skilled nursing facility (SNF) consolidated billing. 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 (FI)/A/B MAC to the SNF. These bundled services are to be billed by the SNF to the FI/A/B MAC in a consolidated bill. The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay. Section 4432 (b) of the Balanced Budget Act (BBA) requires consolidated billing for SNFs. Under the consolidated billing requirement, the SNF must submit all Medicare claims for all the services that its residents receive under Part A, except for certain excluded services described in § 20.1–20.3, and for all physical, occupational and speech-language pathology services received by residents under Part B. Physicians’ professional services are excluded from this consolidated billing requirement; however, the technical and facility based components of physician services delivered to SNF inpatients are bundled into the Part A PPS payment and are not paid separately under Part B.
  • A4221 excessive units. The description of the procedure code A4221 is "supplies for maintenance of drug infusion catheter, per week". The overpayment is anything paid over once a week.
  • Prosthetic bundling. When prosthetics are provided, prosthetic substitutions and or additions of procedures and components are covered in accordance with the functional level assessment, except for certain identified codes cited which will be denied as not medically necessary.
To stay on top of the latest RAC-approved issues in your state, visit the “Tools” Section of the Revenue Cycle Institute Web site and download the updated chart at the top of the page.



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