Compliance Newsletter Clarifies Recent RAC Findings

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  • June 10, 2011
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The April edition of the Centers for Medicare & Medicaid Services’ (CMS’) freely distributed Medicare Quarterly Provider Compliance Newsletter tackles a variety of payment issues that affect inpatient rehabilitation facilities, physicians, non-physician practitioners (NPPs), radiology suppliers, and inpatient and outpatient hospitals. Billing staff should be on the lookout for the claims errors highlighted in this publication, and take steps to prevent them.
The general format of the newsletter describes each problem identified by Medicare claims processing contractors, recovery audit contractors (RACs), program safeguard contractors, zone program integrity contractors (ZPICs), and other governmental organizations, such as the Office of Inspector General (OIG). It then explains the issues that may occur as a result of the error, the steps CMS has taken to make providers aware of the problem, and guidance on what providers need to do to avoid repeating the error or improper activity. The newsletter also refers providers to other documents for more detailed information.
Among the common billing errors identified in this edition is that for oxaliplatin. Contractors and auditors continue to find many outpatient hospitals incorrectly calculating the number of service units billed for this anti-cancer chemotherapeutic agent for the treatment of colorectal cancer.
CMS restates that, for outpatient services furnished on or after Jan. 1, 2006, hospitals should use HCPCS Level II code J9263 Injection Oxaliplatin 0.5 mg to report administration of this drug. The confusion, CMS says, may come from previous policy that instructed hospitals to use HCPCS Level II code C9205 Injection, Oxaliplatin, per 5 mg. The major difference between doses (0.5 mg and 5 mg) often results in hospitals billing too many units. Refer to the newsletter for examples on how this drug should be billed and links to additional Medicare guidance.
Speaking of billing too many units, another issue identified in the newsletter is that for physicians, NPPs, and outpatient hospitals billing excessive units of untimed codes. CMS instructs these providers to use untimed codes to bill for services not defined by specific timeframes; but no matter how long the evaluation or service takes, bill only one unit of an untimed code for a patient, per date of service (some exceptions apply).
Another RAC finding highlighted in the April newsletter involves the technical component (TC) of radiology provided by suppliers, physicians, and NPPs. CMS reminds these providers that the TC of radiology services in a Patient Perspective System (PPS) hospital setting cannot be billed separately to Part B. Medicare reimburses the hospital, and radiology suppliers should bill the hospital, not the Medicare contractor.
The newsletter also regularly includes a brief synopsis of a variety of Special Edition (SE) articles regarding OIG findings. In this edition, CMS highlights the following:
SE1102 Inappropriate Medicare Payments for Transforaminal Epidural Injection Services
SE1103 Capped Rental DME: Enforcement of Payment Requirements for Beneficiary-owned Capped Rental DME
SE1104 The Importance of Correctly Coding the Place of Service by Physicians and their Billing Agents
Read the newsletter for complete details.

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