MEDICARE RECOVERY AUDIT CONTRACTORS

Transcription

1 MEDICARE RECOVERY AUDIT CONTRACTORS RAC ROUND-UP SUBSCRIPTION SERVICE RACS: What Are We Learning? Newly Approved Issues: Part 2 September 1, Aegis Compliance & Ethics Center, LLP 1 1

2 Faculty Brian Annulis, JD Partner, Meade & Roach, LLP Ryan Meade, JD Partner, Meade & Roach, LLP Aegis Compliance & Ethics Center, LLP 2 2

3 RAC Round-Up Subscription Service: Audio-Course Overview RACs: Being Proactive Second Tuesday of each month Discuss one or two high-risk areas for RAC review Review ideas on how to proactively audit Propose operational safeguards RACs: What are We Learning Fourth Tuesday of each month Keep subscribers up-to-date on RAC developments Discuss RAC updates Analyze publicly available decisions involving RACs Pool questions from subscribers 2009 Aegis Compliance & Ethics Center, LLP 3 3

4 RAC Round-Up Subscription Service: Audio-Course Overview Regularly scheduled Audio-Courses will be supplemented, as necessary, with special emergency sessions Administrative Matters Each session will be 75 minutes in duration, including a question and answer session Each session will begin at 12:00 PM CT If you are unable to participate in the live discussion, each session will be recorded and made available in MP3 format No charge for August or September Audio- Courses! 2009 Aegis Compliance & Ethics Center, LLP 4 4

5 Goals The goals of the RAC Round-Up Audio-Courses: Teaching/knowledge transfer Practical points Assist organizations to develop in-house methods of managing Please share your thoughts, suggestions (and criticisms) Our Perspective Defend your claims: Appeals process is critical Manage your compliance risks: Compliance implications to a RAC review must be addressed the RAC process is not just about RAC recovery Be proactive and preemptive 2009 Aegis Compliance & Ethics Center, LLP 5 5

6 Today s Topic and Agenda What Are We Learning? Newly approved audit issues (TODAY) 2009 Aegis Compliance & Ethics Center, LLP 6 6

7 Regions with Approved Issues Region A DCS (Northeast): 0 Region B CGI (eastern-midwest): 3 Region C Connolly (South, Southeast): 8 Region D HDI (West, western-midwest): Aegis Compliance & Ethics Center, LLP 7 7

8 Newly Approved Audit Issues New Audit Issues approved by CMS 1. Clinical Social Worker Services (Region C FL only) 2. Excessive Units Blood Transfusions 3. Excessive Units Untimed Codes 4. Excessive Units IV Hydration Therapy 5. Excessive Units Bronchoscopy Services 6. Once in a Lifetime Procedures 7. Pediatric Codes Exceeding Age Parameters 8. J2505: Injection, Pegfilgrastim (Neulasta), 6 mg 2009 Aegis Compliance & Ethics Center, LLP 8 8

9 A Note on Medicare Rules Where are the Medicare rules? Statutes Regulations CMS Manuals Benefit Policy Manual Claims Processing Manual National Coverage Determinations Transmittals MedLearn Matters Local Contractors: Local Coverage Determinations Medical Director Articles Misc: CPT rules ICD-9 rules Revenue Code rules 2009 Aegis Compliance & Ethics Center, LLP 9 9

10 Clinical Social Worker Services (Region C FL only) RAC Concern: Clinical Social Worker (CSW) services rendered during an Inpatient Hospital stay are not separately payable under Medicare Part B; they are included in the facility s Prospective Payment System (PPS) payment. CSW providers are expected to seek reimbursement from the facility. Provider Types Affected: CSW Providers Medicare Benefit Policy Manual, Ch. 15, Sec. 170 See also, MedLearn Matters SE0439 regarding SNF inpatient coverage 2009 Aegis Compliance & Ethics Center, LLP 10

11 Clinical Social Worker Services (Region C FL only) Benefit Policy Manual Rule: Covered: When service could be performed by a physician or is performed incident to a physician s service Non-covered: Services of a CSW are not covered when furnished to inpatients of a hospital or to inpatients of a SNF if the services furnished in the SNF are those that the SNF is required to furnish as a condition of participation in Medicare. In addition, CSW services are not covered if they are otherwise excluded from Medicare coverage even though a CSW is authorized by State law to perform them. For example, the Medicare law excludes from coverage services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member Aegis Compliance & Ethics Center, LLP 11

12 Clinical Social Worker Services (Region C FL only) What to do? Check if a provider attempting to bill any CSW services to Medicare Part B while patient is in a hospital or SNF inpatient setting? If so, likely non-compliance Check if in-office or home visit meets coverage rule and check State laws on scope of CSW s scope of practice 2009 Aegis Compliance & Ethics Center, LLP 12

13 Excessive Units Blood Transfusions RAC Concern: CPT codes 36430, 36440, 36450, and (excluding claims with any modifiers) should be billed as one (1) per session, regardless of the number of units transfused on that date of service. Medicare Claims Processing Manual, Ch. 12, Sec NCD 110.7: Blood Transfusions CPT Codes 36430: transfusion, blood or blood components 36440: push transfusion, under 2 years 36450: exchange transfusion, newborn 36455: transfusion, other than newborn 2009 Aegis Compliance & Ethics Center, LLP 13

14 Excessive Units Blood Transfusions Benefit Policy Rule: To report charges for transfusion services, OPPS providers should bill the appropriate CPT code for the specific transfusion service provided under Revenue Code 391 (Blood Administration). Transfusion services codes are billed on a per service basis, and not by the number of units of blood product transfused. For payment, a blood product HCPCS code is required when billing a transfusion service code. A transfusion APC will be paid to the OPPS provider for transfusing blood products once per day, regardless of the number of units or different types of blood products transfused. Structure of rule makes it easy target for automated review 2009 Aegis Compliance & Ethics Center, LLP 14

15 Excessive Units Blood Transfusions What to do? Review blood administration CPT codes for billing for more than 1 unit per day Review revenue code sfor billing for more than 1 unit per day If identify more than 1 unit per day, repay reimbursement and determine root cause for excessive units 2009 Aegis Compliance & Ethics Center, LLP 15

16 Excessive Units Untimed Codes RAC Concern: CPT Codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service. Outpatient rehabilitation Medicare Claims Processing Manual, Ch. 5, Sec. 20.2(B) 2009 Aegis Compliance & Ethics Center, LLP 16

17 Excessive Units Untimed Codes Claims Processing Manual: When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe ( untimed HCPCS), the provider enters 1 in the field labeled units. For untimed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition (often once per day). EXAMPLE: A beneficiary received a speech-language pathology evaluation represented by HCPCS untimed code Regardless of the number of minutes spent providing this service only one unit of service is appropriately billed on the same day Aegis Compliance & Ethics Center, LLP 17

18 Untimed Codes List From Claims Process Manual, Ch. 5, Sec. 20.2(D) : Speech/hearing evaluation : Oral speech device eval : Motion fluroscopy/swallow : Endoscope swallow test (fees) : Laryngoscopic sensory test : Fees w/laryngeal sense test : Limb muscle testing, manual : Limb muscle testing, manual : Developmental test, lim : Developmental test, extend : PT evaluation : PT re-evaluation : OT evaluation : OT re-evaluation 2009 Aegis Compliance & Ethics Center, LLP 18

19 Excessive Units Untimed Codes What to do? Does the organization bill for outpatient rehabilitation services? If so, then conduct review. Review untimed CPT for billing for more than 1 unit per day If identify more than 1 unit per day, repay reimbursement and determine root cause for excessive units 2009 Aegis Compliance & Ethics Center, LLP 19

20 Excessive Units IV Hydration Therapy RAC Concern: Based on the definition of CPT (excluding claims modifier-59 ), the maximum number of units should be one (1) per patient per date of service. Beginning , code was replaced with code Medicare Claims Processing Manual, Ch. 12, Sec. 30.5(E) One-Time Notification Manual Code Changes MedLearn Matters Aegis Compliance & Ethics Center, LLP 20

21 Excessive Units IV Hydration Therapy Claims Processing Manual: B. Hydration The hydration codes are used to report a hydration IV infusion which consists of a pre-packaged fluid and /or electrolytes (e.g. normal saline, D5-1/2 normal saline +30 mg EqKC1/liter) but are not used to report infusion of drugs or other substances Aegis Compliance & Ethics Center, LLP 21

22 Excessive Units IV Hydration Therapy Highmark Article (A /12/2008): Hydration Administration (96360, 96361) Medicare currently permits separate payment of hydration therapy provided sequentially (but not concurrently) to chemotherapy infusion. Codes and are intended to report a hydration IV infusion consisting of a prepackaged fluid and/or electrolyte solutions (e.g., normal saline, D5-1/2 normal saline +30mEq KC1/liter), but are not used to report infusion of drugs or other substances. Hydration IV infusion typically requires direct physician supervision for purposes of consent, safety oversight or intra-service supervision of staff. Typically such infusions require little special handling to prepare or dispose of, and staff which administer these do not typically require advanced training. After initial set up, infusion typically entails little patient risk and thus little monitoring Aegis Compliance & Ethics Center, LLP 22

23 Excessive Units IV Hydration Therapy Hydration Coding Changes January 1, 2009: became 96360: Hydration iv infusion, initial 31 minutes to 1 hour became : Hydration iv infusion, add-on each additional hour 2009 Aegis Compliance & Ethics Center, LLP 23

24 Excessive Units IV Hydration Therapy What to do? Review use of prior to January 1, 2009 to determine if used more than 1 time per day. Review use of after January 1, 2009 to determine if used more than 1 time per day. Possible RAC Challenge? If find the codes being used more than 1 time per day, is there medical necessity? RAC is basing review on its interpretation of the definition of the CPT code Aegis Compliance & Ethics Center, LLP 24

25 Excessive Units Bronchoscopy Services RAC Concern: CPT Codes 31625, and should be billed with a maximum number of units of one (1) per patient per date of service (excluding claims with modifier 59) should only be reported with one unit per date of service. RAC cites practice guidelines: American Thoracic Society Region C: Cypress College Health Sciences Division (?) 2009 Aegis Compliance & Ethics Center, LLP 25

26 Excessive Units Bronchoscopy Services 31625: Bronchoscopy with biopsy(s) 31628: Bronchoscopy, with transbronchial lung biopsy, single lobe 31629: Bronchoscopy; with transbronchial needle aspiration biopsy, trachea, main stem and/or lobar bronchus 2009 Aegis Compliance & Ethics Center, LLP 26

27 Excessive Units Bronchoscopy Services American Thoracic Society Coding & Billing Quarterly (July 2009) Multiple Bronchoscopies Q. My coders are only letting us report one bronchoscopy code, regardless of what we perform and document. Can you provide supporting information to help convince them to report bronchoscopies appropriately? A. Your coders are incorrect and are denying you and your institution a range of appropriate codes for reporting bronchoscopic services. The ATS Coding & Billing Quarterly has published a series of articles and Q & A s on appropriate use of the family of bronchoscopic codes (please see the July and September 2008 issues). We recommend you and your billing staff refer to these issues for proper use of bronchscopic codes. Back issues of the ATS Coding & Billing Quarterly are archived on the ATS Web site at Aegis Compliance & Ethics Center, LLP 27

28 Excessive Units Bronchoscopy Services American Thoracic Society Coding & Billing Quarterly (July 2008) Q. If multiple, distinct procedures are performed doing a single bronchoscopy, is it appropriate to report each separately? A. It is appropriate to report multiple procedures performed during a single bronchoscopy. For example, bronchoscopy in a patient with lobar pneumonia to identify the infectious cause might include a bronchial alveolar lavage (31624), a protected brush sampling (31623), and a transbronchial lung biopsy (31628), all during the same session Aegis Compliance & Ethics Center, LLP 28

29 Excessive Units Bronchoscopy Services What to do? Review use of to determine if used more than 1 time per day. Possible RAC Challenge? If find the codes being used more than 1 time per day, is there medical necessity? RAC is basing review on practice guidelines that are not clear or specific 2009 Aegis Compliance & Ethics Center, LLP 29

30 Once in a Lifetime Procedures RAC Concern: By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime. RAC Region C cites nothing RAC Region D cites Medicare Program Integrity Manual, Ch. 3, Sec. 3.6 (not on point) 2009 Aegis Compliance & Ethics Center, LLP 30

31 Once in a Lifetime Procedures Focus of RACs: Hospital outpatient Physician professional fees Examples? Amputations Appendectomy Gall bladder removal 2009 Aegis Compliance & Ethics Center, LLP 31

32 Pediatric Codes Exceeding Age Parameters RAC Concern: Region C: Newborn/Pediatric CPT codes being applied/billed for patients which exceed the age limit defined by the CPT code. Region D: Certain service codes are specific to patients of a specific age and should not be applied/billed for patients which exceed the age limit defined by the CPT Code. RAC cites nothing but CPT terminology generally Note: outpatient and physician only 2009 Aegis Compliance & Ethics Center, LLP 32

33 Pediatric Codes Exceeding Age Parameters Examples: Critical Care Code: 99293: 29 days through 25 months 99294: 29 days through 25 months 99295: 28 days of age or less 99296: 28 days of age or less But note: These codes eliminated January 1, Aegis Compliance & Ethics Center, LLP 33

34 J2505: Injection, Pegfilgrastim (Neulasta), 6 mg RAC Concern: Region C: By definition HCPC Code J2505 represents 6 mg per unit. The code should be billed at one (1) unit per patient per date of service. Region D: Neulasta (HCPCS code J2505) Claims submitted with the total number of milligrams instead 1 unit per 6mg. Claims for J2505 should be submitted so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs Aegis Compliance & Ethics Center, LLP 34

35 J2505: Injection, Pegfilgrastim (Neulasta), 6 mg RAC Cites: Transmittal 949 (dated May 12, 2006) MLN Matters Number MM5912 (January 18, 2008) MLN Matters Number MM4380 (May 12, 2006) 2009 Aegis Compliance & Ethics Center, LLP 35

36 J2505: Injection, Pegfilgrastim (Neulasta), 6 mg Transmittal: Claims for Pegfilgrastim J2505 shall be submitted to Medicare contractors so that the units billed represent the number of multiples of 6MG provided, not the number of MGs. MedLearn Matters: The Centers for Medicare & Medicaid Services (CMS) learned that providers are billing incorrectly for Pegfilgrastim. An analysis of claims revealed a number of providers billing multiple units of J2505 per date of service. CMS also noted that many providers billing multiple units of J2505 were consistently billing 6 units per date of service, indicating that 36mg of Pefilgrastim were given Aegis Compliance & Ethics Center, LLP 36

37 J2505: Injection, Pegfilgrastim (Neulasta), 6 mg What to do? Review sample of claims billing for J2505 to determine if billing in units of by mg. If billing by mg, then understand root cause If root cause of error is systemic or in charge master, then refund may be necessary Review whether J2505 has been billed with more than 6 units If so, then was payment received? If payment received, then refund 2009 Aegis Compliance & Ethics Center, LLP 37

38 RAC Subscription Service Overview Monthly subscription service starting October 1, 2009 AudioCourse access Organic RAC tools Guidebook, with updates Tracking/management software RAC resource clearinghouse Workshop discounts: 1 st workshop: October 26 & 27 Chicago 2009 Aegis Compliance & Ethics Center, LLP 38

39 Follow-Up Questions? Next Lecture: Tuesday, September 8, 2009 RAC: Being Proactive Physician Supervision 12pm CT/1pm ET 2009 Aegis Compliance & Ethics Center, LLP 39