Home Health News

As we have previously reported, RAC auditors are prohibited from investigating overpayments arising from any clinical or administrative issues that were not on the table during the 3-year RAC demonstration project. One by one, the collection agencies that hold RAC contracts have been adding to the list of issues, applying for and getting CMS approval for issues not addressed during the demonstration. Below is a complete list of issues approved by CMS since the demonstration project ended and permanent contracts were awarded. As you will see from this week’s list, RACs are not looking at home care yet.

1-Newborn Pediatric CPT Codes Billed for Patients 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.

2-Once in a Lifetime Event

Certain procedures are only performed once in a persons lifetime. Query identifies claims paid for those procedures for more than one service date.

Reference: CMS Pub 100-08, Ch. 3, § 3.6.

3-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.
Reference: CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-11 CMS Pub 100-04, Ch. 5, § 20.2

4-Excessive Units-Blood Transfusions

Blood Transfusions should be billed with a maximum of (1) unit per patient per date of service.
Reference: 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

5-Excessive Units-Bronchoscopy

Bronchoscopy services should be billed with a maximum number of units (1) per patient per date of service.
Reference: 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

6-Excessive Units- IV Hydration

IV Hydration should be billed with a maximum number of units (1) per patient per date of service.
Reference: 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

7-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.
Reference: 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

8-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.
Reference: CMS Pub.100-3, Ch1, § 230.17 Noridian LCD Policy Article A25377

9-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.
Reference: CMS Pub 100-03, Ch 1, § 280.1 & 280.3 Noridian LCD Policy A19846

10-Knee Orthotic Bundling

There are Knee orthotic addition codes that cannot be billed separately due to the fact that they are bundled with the base knee orthotic code or that the addition code is not medically necessary when billed in conjunction with a specific knee orthotic base code.

11-PEN supplies more than 1 time a day

The description or the billing guidelines state parenteral/enteral nutrition codes are allowed once a day.
Reference: 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