Training Programs
Audits & Assessments
Regulatory MonitoringArchive for December, 2008
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DRG 186–187—Pleural effusion with complication/comorbidities(CC) or major CC (MCC)
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86.22—Debridement
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DRG 813—Coagulation disorders
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DRG 870–871—Septicemia
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54.51 and 54.50—Lysis of adhesions
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DRGs 981–989—For operating room procedures unrelated to the principal diagnosis
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DRG 551—Medical back problems
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DRG 313—Chest pain
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DRGs 377–379—Gastrointestinal hemorrhage with MCC, CC or without CC/MCC
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DRGs 640–641—Nutritional and miscellaneous metabolic disorders with MCC or without MCC (e.g. dehydration)
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DRG 291–293—Heart failure and shock with MCC, with CC or without CC/MCC (e.g. congestive heart failure)
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DRG 689–690—Kidney and urinary tract infections with MCC or without MCC
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DRG 682–684—Renal failure with MCC, with CC or without CC/MCC
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DRG 811–812—Red blood cell disorders with MCC or without MCC
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DRG 286–287—Circulatory disorders except AMI, with cardiac catheterization with MCC or without MCC
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DRG 264—Other circulatory system operating room procedures
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DRG 190–192—Chronic obstructive pulmonary disease (COPD) with MCC, with CC or without CC/MCC
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DRG 166–168—Other respiratory system operating room.procedures with MCC, with CC or without CC/MCC (e.g. transbronchial lung biopsy)
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DRG 222–227—Cardiac defibrillator implantations with or without cardiac catheterization
Editor’s note: This tip is excerpted from HCPro, Inc.’s new book, The HIM Director’s Guide to Recovery Audit Contractors, by Jean S. Clark, RHIA. For more information on the book, click here.
Q: If I receive a demand letter from a RAC because a service didn’t meet Medicare’s medical necessity criteria for an inpatient level of service, can we re-bill all the services on an outpatient claim?A: Providers can re-bill for Inpatient Part B services, also known as ancillary services, but only for the services on the list in the Benefit Policy Manual. That list can be found in chapter 6, section 10: www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf. Rebilling for any service will only be allowed if all claim processing rules and claim timeliness rules are met. There are no exceptions to the rules in the national program. The time limit for re-billing claims is 15–27 months from the date of service. These normal timely filing rules can be found in the Claims Processing Manual, chapter 1, section 70: www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
Editor’s note: Thanks to Barbara Aubry, RN, CPC, CHCQM, FAIHQ, regulatory analyst for 3M Health Information Systems, Inc, in Rockleigh, NJ, for providing this response.
CMS updates: Contacting CMS in regards to RAC-reviewed claims and RAC ODF transcripts
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro
Happy holidays everyone! I thought I would do a follow-up to last week’s note by Hugh Aaron about physician supervision. One of the clarifications that I have discussed with many people recently is related to nurse practitioners (NP) or physician assistants (PA). CMS clarified that NPs/PAs may not provide the physician supervision in provider-based departments. This fact was not a surprise to most, but the impact for NP/PA rendered services should be considered.
These extension providers often provide care in hospital-based clinics, such as urgent care centers or fast track facilities, without a physician being present in the department; in fact, they sometimes “cover” when the physician is unable to be present. However, the facility portion of this service is a hospital service subject to direct supervision under the hospital regulations.[1] Therefore, in accordance with the direct supervision guidelines discussed in the most recent OPPS final rule, a physician must be present in the department for the hospital facility service to be covered by Medicare.
Some confusion has arisen because these visits are generally appropriate under most state laws that allow NPs/PAs to practice without a physician on the premises. Additionally, the professional service by a NP/PA need not be under direct supervision for the service to be billable as a covered professional service to Medicare. The NP/PA would simply bill under his or her own NPI and be paid at a lower rate. Because the service is provided within the NP/PA’s scope of service (and is generally thought of as a professional service), many providers have not considered that the hospital direct supervision requirements apply to the facility portion—and that without a physician present, the hospital facility service is not covered.
I encourage providers to review the guidance on NPs/PAs in the OPPS final rule and evaluate locations where these extension providers might be providing services without a physician present some or all of the time.
[1] The regulations exempt rural health clinics and federally qualified health centers from the direct supervision requirements.
CMS issues annual clotting factor furnishing fee update
On December 19, CMS issued its annual update to the furnishing fee for clotting factor.
Effective date: January 1, 2009
Implementation date: January 5, 2009
CMS announces new waived tests under CLIA
On December 19, CMS announced new waived tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).
Effective date: January 1, 2009
Implementation date: January 5, 2009
CMS issues transmittal on the 2009 update for clinical laboratory fee schedule and laboratory services subject to reasonable charge payment
On December 19, CMS issued a transmittal providing instructions for the CY 2009 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment.
Effective date: January 1, 2009
Implementation date: January 5, 2009
CMS rescinds and replaces previous transmittal on paying claims without passing through editors
On December 18, CMS rescinded and replaced its previous transmittal regarding paying claims without passing through the integrated outpatient code editor or the Medicare code editor. Most information remains the same.
Effective date: November 25, 2008
Implementation date: November 25, 2008
CMS adds codes covered under serum iron studies NCD
On December 18, CMS extended coverage under the serum iron studies NCD to ICD-9-CM codes 285.22 and 285.29.
OIG seeks suggestions on safe harbors, fraud alerts
On December 17, the OIG published a notice in the Federal Register to solicit proposals and recommendations for developing and modifying safe harbor provisions under the Federal anti-kickback statute (section 1128B(b) of the Social Security Act), as well as developing new OIG special fraud alerts.
View the Federal Register notice.
OIG issues review of high-dollar payments for outpatient services processed by Palmetto GBA for the period January 1, 2004, through December 31, 2005
On December 17, the OIG issued a review of high-dollar payments for outpatient services processed by Palmetto GBA, a fiscal intermediary, for the period January 1, 2004, through December 31, 2005. The OIG determined that during this period, Palmetto made 22 inappropriate payments, including overpayments totaling $1.8 million.
OIG issues reports on adverse events
On December 16, the OIG issued two reports on adverse events in the hospital setting.
CMS launches annual provider satisfaction survey
On December 16, CMS announced the launch of its annual survey of providers’ satisfaction with Medicare contractors. CMS will send the survey to randomly selected providers.
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