Source: https://performantrac.com/audit-regions/region-1/
Timestamp: 2019-06-18 17:17:45
Document Index: 409192791

Matched Legal Cases: ['§414', '§419', '§405', 'arty 5', '§405', '§3', '§ 10', '§20', '§20', '§20', '§40', '§20', '§405', 'arty 4', '§405', '§3', '§405', 'arty 4', '§405', '§ 414', '§3', '§3', '§ 40', '§20', '§ 20', '§ 110']

Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements
_0157
Place of Service 24 with Type of Service “F”
Issue Name: Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements
Issue Number: _0157
Provider Type: Place of Service 24 with Type of Service “F”
Date Approved: 06/26/2019
Dates Service: Exclude from review claims having a “claim paid date” which is more than 3 years prior to the ADR date
Description: Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers. Documentation will be reviewed to determine if the billed procedures meets Medicare coverage criteria and applicable coding guidelines for the use of modifier 73.
References: "1.	Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2.	42 CFR §414.40 Coding and Ancillary Policies 3.	42 CFR §419.44 Payment Reductions for Procedures 4.	42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 5.	42 CFR §405.986- Good Cause for Reopening 6.	Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations 7.	Medicare Claims Processing Manual, Chapter 4 Part B Hospital (Including Inpatient Hospital Part B and OPPS), § 10.5 Discounting; §20.6 Use of Modifiers, §20.6.1 Where to Report Modifiers on the Hospital Part B Claim, and §20.6.4 Use of Modifiers for Discontinued Services 8.	Medicare Claims Processing Manual, Chapter 14 Ambulatory Surgical Centers, §40.4 Payment for Terminated Procedures 9.	Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements, §20.3 Use and Acceptance of HCPCS Codes and Modifiers 10.	American Medical Association (AMA), Current Procedural Terminology, Appendix A Modifiers 11.	AHA Coding Clinic for HCPCS 2007, Volume 7, Number 1, Page 1 Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS 12.	AHA Coding Clinic for HCPCS 2008, Volume 8, Number 2, Pages 1-4 Special Issue: Modifiers 52, 73, and 74 13.	AHA Coding Clinic for HCPCS 2016, Volume 16, Number 1, Page 12 Appropriate Use of Modifiers for Discontinued Services under the OPPS 14.	AMA CPT Assistant, September 2003, Page 3 Hospital Outpatient Reporting Part IV: Use of the CPT Modifiers ’52,’ ’58,’ ’59,’ ’73,’ ’74,’ ’76,’ ’77,’ ’78,’ and ‘91’"
Ophthalmic Diagnostic CPT Codes: Excessive Units
_0159
Issue Name: Ophthalmic Diagnostic CPT Codes: Excessive Units
Issue Number: _0159
Date Approved: 06/17/2019
Description: CPT codes 92133 and/or 92134 will be considered in this edit, if billed together during the same patient encounter, on the same date of service. Only one is allowed per day, therefore the lower allowed amount CPT Code will be recovered as an overpayment. Based on CPT Code descriptions, CPT Code 92133 and/or 92134 cannot be reported at the same patient encounter.
References: "1.	Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2.	Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3.	42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 4.	42 CFR §405.986- Good Cause for Reopening 5.	Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 6.	American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 – current (Special Ophthalmological Services)"
References: 1.	Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2.	Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3.	42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 4.	42 CFR §405.986- Good Cause for Reopening 5.	42 CFR § 414.B Payment for Part B Medical and Other Health Services- Coding and Ancillary Policies 6.	Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 7.	Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions §3.6.2.4- Coding Determinations 8.	Medicare Claims Processing Manual, Chapter 12- Physician/ Non-physician Practitioners § 40.1- Definition of a Global Surgical Package 9.	Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §20.3- Rebundling of CPT Codes; 40.1- Payment to Ambulatory Surgical Centers for non-ASC Services; 40.5- Payment for Multiple Procedures 10.	American Medical Association (AMA), Current Procedure Terminology 11.	ASC Payment System; Addendum AA; Payment indicators: G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight); J8 (Device-intensive procedure; paid at adjusted rate).ASC Payment rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html 12.	National Correct Coding Initiative Policy Manual 13.	American Medical Association CPT Assistant 14.	American Hospital Association Coding Clinic for HCPCS
ASC Services During a Covered Part A SNF Stay
_0142
"Ambulatory Surgery Center (ASC) SNF"
Issue Name: ASC Services During a Covered Part A SNF Stay
Issue Number: _0142
Provider Type: "Ambulatory Surgery Center (ASC) SNF"
Date Approved: 04/01/2019
Description: Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions. Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing – Part A MAC Updates for years: 2015, 2016, 2017 and 2018 are overpayments and will be recovered.Affected codes: See 0142 Appendix D
References: "1)	Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2)	Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 3)	Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 6 SNF Inpatient Part A Billing and SNF Consolidated Billing, § 20.1.2: Other Excluded Services Beyond the Scope of a SNF Part A Benefit https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf 4)	Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 6 SNF Inpatient Part A Billing and SNF Consolidated Billing, § 110.2.7: Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf 5)	OIG Report: Payments for Ambulatory Surgical Center Services Provided to Beneficiaries in Skilled Nursing Facility Stays Covered Under Medicare Part A in Calendar Years 2006 through 2008 (A-01-0900521) December 2010 https://oig.hhs.gov/oas/reports/region1/10900521.pdf 6)	SNF Consolidated Billing – Annual Updates for Part A MAC – 2015, 2016, 2017 and 2018 https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2015-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2016-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2017-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-A-MAC-Update.html 7)	SNF Consolidated Billing – General Explanation of the Major Categories for Skilled Nursing Facility – https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2018-General-Explanation.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2017-General-Explanation.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2016-General-Explanations.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2015-General-Explanation.pdf "