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A new study shows Medicare’s policy against paying for hospital acquired conditions (HAC) will only save the $400 billion program $1.1 million to $2.7 million.
California researchers conducted the study, according to a Wall Street Journal article. The researchers studied discharge data from California Medicare beneficiaries in 2006, looking for six conditions the authors deemed definable, according to the article. Out of the total 767,995 cases, there were 828 cases of those conditions, and 26 would have been subject to lower payments.
CMS reminds contractors of annual HCPCS update
On September 4, CMS issued a transmittal to remind contractors of the annual HCPCS update.
Effective date: January 1, 2010
Implementation date: January 4, 2010
CMS instructs on HIPAA 5010 implementation for the 835
On September 4, CMS issued a transmittal instructing contractors on implementation of version 5010 of the 835.
OIG issues report on high-dollar claims
On August 26, the OIG issued a report on high-dollar claims paid by CareFirst of Maryland, previously a Medicare fiscal intermediary. The OIG found that, between January 1, 2003, and September 30, 2005, CareFirst overpaid $1.2 million for 24 high-dollar payments it made for hospital outpatient claims in Maryland and the District of Columbia.
Connolly, the RAC for Region C, approved several issues for North Carolina providers on September 10.
The following issues have been approved for outpatient hospitals and physicians in North Carolina:
- Untimed codes
- Once in a lifetime procedures
- Pediatric codes exceeding age parameters
- J2505: Injection, Pegfilgrastim, 6 mg
Connolly may also audit Durable Medical Equipment (DME) providers in North Carolina for Wheelchair bundling and Urological bundling.
By Judith Kares, an regulatory specialist for HCPro, Inc.
On August 28, CMS issued Medicare Claims Processing Manual (MCPM) transmittal 1803, which is the October 2009 update to the Outpatient Prospective Payment System (OPPS). CMS included minor revisions to those sections of Chapter 1 of the MCPM that relate to condition code 44.
As you will recall, condition code 44 is used when a patient’s initial inpatient status is successfully changed to outpatient for purposes of billing and payment. This generally occurs when case management and other utilization review personnel were not available (weekends and holidays) at the time that the admission decision was made, and it is later determined that the patient does not meet Medicare’s inpatient guidelines. Condition code 44 is reported on the subsequent outpatient (013X) type of bill that is submitted to recover the services provided in the inpatient setting.
CMS released several MLN Matters articles related to transmittals previously outlined in Medicare Weekly Update.
- Addition/Deletion of HCPCS Codes – October 2009 Quarterly Update (MM6594)
- October 2009 Integrated Outpatient Code Editor (I/OCE) Specifications Version 10.3 (MM6618)
- October 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) (MM6626)
- Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for Fiscal Year (FY) 2010 (MM6607)
- October 2009 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (MM6585)
- Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens (MM6524)
CMS also released a special edition MLN Matters article:
- Billing for the Administration of the Influenza A (H1N1) Virus Vaccine (SE0920)
Join MedicareFind today for a direct link to these and all the documents in our regulatory database.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc
CMS recently issued Medicare Claims Processing Manual Transmittal 1799 (CR 6570), which is a Recurring Update Notification to inform contractors of new waived tests approved by the Food and Drug Administration under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Since these tests are marketed immediately after approval, CMS must notify its contractors of the new tests so that the contractors can accurately process claims. This seems like a good time to review the basic guidelines set out under CLIA with respect to waived tests.
The following ICD-9-CM codes denote acute respiratory failure (ARF):
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518.81, ARF
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518.82, other pulmonary insufficiency, not elsewhere classified (includes acute respiratory distress, acute respiratory insufficiency, and adult respiratory distress syndrome NEC)
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518.84, acute and chronic respiratory failure
Check out Coding Clinic, fourth quarter 1998 and first quarter 2005, for more information about when ARF should be the principal diagnosis, as well as documentation requirements.
The sequencing of respiratory failure depends on the reason for admission. When respiratory failure from an underlying condition causes the inpatient admission, the failure becomes the principal diagnosis; when the patient develops respiratory failure after admission, it is the secondary diagnosis and should be coded as such.
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