Source: https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx?State=OR
Timestamp: 2018-01-18 11:45:11
Document Index: 638429540

Matched Legal Cases: ['§ 3', '§ 20', '§ 231', '§ 230', '§ 280', '§ 120', '§ 20', '§ 20', '§ 80', '§ 170', '§ 20', '§ 20', '§40', '§140', '§ 10', '§ 10', '§ 10', '§ 211']

New Issues Approved by CMS
All new issues that are identified by HDI must first be approved by CMS.
Number of Records per Page 20 50 100
Region D States
Region D MACS
Once in a Lifetime Certain procedures are only performed once in a persons lifetime. Query identifies claims paid for those procedures for more than one service date. D000322009 Professional Services (Physician/Non-Physician Practitioner); Outpatient Hospital Automated 06/11/2009 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 CMS Pub 100-08, Ch. 3, § 3.6.
PEN supplies more than 1 time a day The description or the billing guidelines state parenteral/enteral nutrition codes are allowed once a day. D000192009 DME Non-Physician Automated 06/17/2009 All DMEMAC Applies to claims paid on or after October 1, 2007 CMS Pub. 100-3 (National Coverage Determinations Manual), Chapter 1, Section 180.2. LCD L11576 Parenteral Nutrition, LCD L11568 Enteral Nutrition, LCD Policy Article A37077 Parenteral Nutrition
Newborn Pediatric CPT Codes Billed for Pts Exceeding Age Limit 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. D000312009 Professional Services (Physician/Non-Physician Practitioner); Outpatient Hospital Automated 06/17/2009 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 American Medical Association (AMA), Current Procedural Terminology 2007, 2008, 2009
Facility vs. Non-Facility Reimbursement (Inpatient) Under the physician fee schedule, some procedures have a separate Medicare fee schedule for a physician’s professional services when provided in a facility and a nonfacility. The CMS furnishes both fees in the MPFSDB update. Professional fees, when the services are provided in a facility, are applicable to procedures furnished in the facilities. D000212009 Professional Services (Physician/Non-Physician Practitioner) Automated 06/24/2009 08/03/2010 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 CMS Pub 100-04; Chapter 12, § 20.4.2
Neulasta 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. D000182009 Professional Services (Physician/Non-Physician Practitioner) Automated 06/24/2009 04/28/2014 All Region D States AB MACs Applies to claims paid on or after October 1, 2007 CMS Manual System, Publication 100-04 Medicare Processing Manual, Transmittal 949 (dated May 12, 2006, MLN Matters Number MM5912, Release Date, January 18, 2008,HCPCS Level II 2007, 2008, 2009
Excessive Units-Blood Transfusions Blood Transfusions should be billed with a maximum of (1) unit per patient per date of service. D000342009 Professional Services (Physician/Non-Physician Practitioner); Outpatient Hospital Automated 06/24/2009 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 Federal Register, Volume 67, No.212, (11/01/02) page 66868. Program Memorandum Intermediaries, Transmittal A-01-50, April 12, 2001, page 1 CMS Pub 100-04, Ch. 4, § 231.8
Excessive Units-Bronchoscopy Bronchoscopy services should be billed with a maximum number of units (1) per patient per date of service. D000352009 Professional Services (Physician/Non-Physician Practitioner); Outpatient Hospital Automated 06/24/2009 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 Federal Register, Volume 67, No. 251, (12/31/02) page 80072. American Medical Association (AMA), Current Procedural Terminology (CPT) American Thoracic Society Coding 2005 Update
Neulasta 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. D000392009 Outpatient Hospital Automated 06/24/2009 All AB MACs FIs Applies to claims paid on or after October 1, 2007 CMS Manual System, Publication 100-04 Medicare Processing Manual, Transmittal 949 (dated May 12, 2006) MLN Matters Number MM5912, Release Date, January 18, 2008 HCPCS Level II 2007, 2008, 2009
Urological bundling A potential vulnerability may exist if certain urological procedure codes are billed in conjunction with other urological procedure codes for the same date of service and same beneficiary. D000032009 DME Non-Physician Automated 06/26/2009 All DMEMAC Applies to claims paid on or after October 1, 2007 CMS Pub.100-3, Ch1, § 230.17 Noridian LCD Policy Article A25377
Wheelchair Bundling Bundling guidelines for wheelchair bases and options/accessories indicate certain procedure codes are part of other procedure codes and, as a result, are not separately payable D000092009 DME Non-Physician Automated 06/26/2009 All DMEMAC Applies to claims paid on or after October 1, 2007 CMS Pub 100-03, Ch 1, § 280.1 & 280.3 Noridian LCD Policy A19846
Global vs TC/PC An overpayment exists when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or professional (modifier 26) components for the same service. D000042009 Professional Services (Physician/Non-Physician Practitioner) Automated 06/26/2009 08/03/2010 All AB MACs Carriers Applies to claims paid on or after October 1, 2007 CMS Pub 100-04; Ch. 1, § 120 CMS Pub 100-04; Ch. 12, § 20.2 CMS Pub 100-04; Ch. 13, § 20.1 - 20.2.3 CMS Pub 100-04; Ch. 16, § 80.2.1
CSW During Inpatient Services of Clinical Social Workers (CSW) rendered during Inpatient Hospital stays are included in the facility’s PPS payment and are not separately payable under Part B. CSW providers are expected to seek reimbursement from the facility. D000072009 Professional Services (Physician/Non-Physician Practitioner) Automated 06/26/2009 08/03/2010 All AB MACs Carriers Applies to claims paid on or after October 1, 2007 CMS Pub 100-02, Chapter 15 § 170; Med Learn Matters MLN SE0439
TC of Radiology Carriers/MAC's may not pay for the technical component (TC) of radiology services furnished to patients in inpatient or outpatient hospital settings. D000102009 Professional Services (Physician/Non-Physician Practitioner) Automated 06/26/2009 08/03/2010 All AB MACs Carriers Applies to claims paid on or after October 1, 2007 OIG Report A-01-04-00528; CMS Pub 100-04, Chapter 13, § 20.2.1; Med Learn Matters #MM537; Change Request 5675
Excessive Units- IV Hydration IV Hydration should be billed with a maximum number of units (1) per patient per date of service. D000362009 Professional Services (Physician/Non-Physician Practitioner); Outpatient Hospital Automated 06/26/2009 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 CMS Pub 100-4 Ch. 12, pages 31-32 CMS Pub100-20, Transmittal 419, page 7. MLN Matters, MM6349 R/T CR Release Date 12.19.08, page 4
Excessive Units-Untimed Codes When reporting service units for untimed codes (excluding Modifiers -KX, and -59) where the procedure is not defined by a specific timeframe, the provider should enter a 1 in the units bill column per date of service. D000332009 Professional Services (Physician/Non-Physician Practitioner); Outpatient Hospital Automated 06/26/2009 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-11 CMS Pub 100-04, Ch. 5, § 20.2
Incorrect Pt Status - Acute Underpayments Acute hospitals have billed incorrect discharge statuses when a patient is transferred to another facility. The reimbursement for the acute hospital was underpaid based on the type of facility the patient was subsequently transferred to or the absence of any subsequent facility claim. D000242009 Inpatient Acute Care Hospital Automated 08/28/2009 09/12/2013 All Region D States AB MACs, FIs Applies to claims paid on or after October 1, 2007 CMS Claims Processing Manual 100-04, Chapter 3 §40.2.4, and MedLearn Matters SE0801, SE0459, MM2934 and MM3829
Incorrect Pt Status - IRF Underpayments Inpatient Rehab Hospital stays that have billed an incorrect discharge status after transferring a patient to another facility. The reimbursement for the inpatient rehab hospital was underpaid based on the type of facility the patient was subsequently transferred to or the absence of any subsequent facility claim. D000252009 Inpatient Rehab Facility Automated 08/28/2009 09/13/2013 All Region D States AB MACs, FIs Applies to claims paid on or after October 1, 2007 CMS Claims Processing Manual 100-04, Chapter 3 §140.2.3, CR 5354, Transmittal R1099CP, OIG Report "Nationwide Review of Inpatient Rehabilitation Facilities' Compliance with Medicare's Transfer Regulation (A-04-04-00008 dated September 2006 and MedLearn Matters SE0801 and SE0459
Hospice Related Services - B Services related to a Hospice terminal diagnosis provided during a Hospice period are included in the Hospice payment and are not paid separately. D000532009 Professional Services (Physician/Non-Physician Practitioner) Automated 09/11/2009 08/03/2010 All AB MACs FIs Carriers Applies to claims paid on or after October 1, 2007 CMS Pub 100-04, Chapter 11, § 10, 40.2 and 50; CMS Pub 100-02, Chapter 9, § 10
SNF Consolidated Billing Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A SNF stay are included in a bundled prospective payment made through the fiscal intermediary (FI)/A/B Medicare Administrative Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI/A/B MAC in a consolidated bill. D000292009 Outpatient Hospital; DME Suppliers, Professional Services (Physician/Non-Physician Practitioner) Automated 09/11/2009 08/03/2010 All DME MAC AB MACs Applies to claims paid on or after October 1, 2007 1) Medicare Claims Processing Manual: CMS Pub 100-04; Chapter 6 § 10, 20, 80 and 110.2.2 2) Medicare Claims Processing Manual: CMS Pub 100-04; Chapter 20 § 211 3) Overview on Skilled Nursing Facility (SNF) Consolidated Billing (CB) 4) Carrier File Explanation SNF Consolidated Billing
A4221 Excessive Units The description of the procedure code A4221 is "SUPPLIES FOR MAINTENANCE OF DRUG INFUSION CATHETER, PER WEEK". The overpayment is anything paid over once a week. D000222009 DME Non-Physician Automated 09/11/2009 All DME MAC Applies to claims paid on or after October 1, 2007 CMS Pub. 100-3 (National Coverage Determinations Manual), Chapter 1, Section 280.14 LCD L11570 External Infusion Pumps