Issues Under Review Affecting Ambulatory Surgery Centers in Region A
ISSUES UNDER REVIEW IN REGION A (DIVERSIFIED COLLECTION SERVICES)
For purposes of conducting internal self-audits, preventing and/or minimizing audits by regional Recovery Audit Contractors ("RAC") and possibly preventing investigations concerning violations of various federal and state false claims act regulations, it is critically important for ASC's to consistently review and monitor the issues under review by their regional RAC.
RAC's are contracted by the Centers for Medicare & Medicaid Services ("CMS") to identify Medicare overpayments and underpayments to health care providers within the RAC's region (including ASC's).
An "overpayment" can occur when health care providers submit claims that do not meet Medicare's coding or medical necessity policies.
An "underpayment" can occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed
While it is impossible to pinpoint the exact areas that RAC's will target when reviewing medical bills submitted to Medicare, each regional RAC is required to post its current "issues under review" and disclose to the public the specific codes and/or procedures currently being audited by automated reviews(where no medical record is involved in the review). It is also important to note that commercial insurance payors often look to the regional RAC's when determining the criteria for their internal audits and "data mining" initiatives and it is very likely that an ASC will be audited and reviewed for similar coding and billing "issues" by both its Regional RAC and commercial insurance payors.
Below are the current issues under review affecting ASC's and similar organizations posted by the "Region A" RAC (reviewing New Jersey and New York). New Jersey and New York based ASC's can to use the issues under review as guidance for internal reviews and self-audits and to further review both (a) the applicable CMS local coverage determinations ("LCDs") and (b) the "issue description" and "issue references" disclosed with the specific "issue under review" so that any issues can be corrected by using an alternate code, submitting claims that are more detailed and/or limiting the services to the allowable beneficiaries, duration, frequency or levels.
The current "issues under review" identified by the Region A RAC - Diversified Collection Services - can be the subject of the Region A RAC's automated reviews for New Jersey and New York ASC's, and are outlined as follows:
Issue Name: Medically Unlikely Units (MUE) Table
Issue Description: Identification of overpayments associated with providers billing the same code in excess of units of service for the same beneficiary on the same date of service as stipulated in CMS MUE Table.
Issue Name: Add-On Codes Paid without a Paid Required Primary Procedure
Issue Description: Claims overpaid for add-on codes when the required primary procedure is not billed on any claim (same or different) for the same date of service.
Issue Name: ECGs with Cardiac Catheterization Procedures
Issue Description: An overpayment may exist when outpatient hospital providers bill separately for ECGs performed the same date of service as cardiac catherization procedures. ECGs unrelated (e.g. peformed prior to or after) the cardiac catherization should be billed with modifier 59.
Issue Name: Colonoscopy - Excess Units
Issue Description: The CPT code descriptors for certain colonoscopy codes includes language that indicates the codes should only be billed once even if multiple sites are treated using the same technique for the same beneficiary and same date of service. This issue identifies overpayments associated to providers billing these colonscopy services with more than one unit of service.
Issue Name: Outpatient Hospital - E/M Code with Status S or T Code
Issue Description: An overpayment exists when a provider bills an evaluation and management code, assigned with status V, without modifier 25 on the same date of service as a significant medical or surgical code, status S and T respectively.
Issue Name: Cataract Removal - Excess Units
Issue Description: Cataract removal can only occur once per eye for the same date of service. This issue identifies overpayments associated to outpatient hospital providers billing more than on unit of cataract removal for the same eye.
Issue Name: National Correct Coding Initiative (CCI) - OPPS
Issue Description: Application of the OPPS National Correct Coding Initiative (Mutually Exclusive and Non-Mutually Exclusive). Deny Column II code when billed by the same provider and same date of service as a Column I code.
Issue Name: Technical Component of Radiology
Issue Description: A potential vulnerability may exist when the technical component (TC) of radiology services are furnished to patients in a Prospective Payment System (PPS) hospital setting and are billed separately to Part B. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
Issue Name: IV Hydration
Issue Description: A potential vulnerability may exist if certain IV Hydration Codes are billed for more than one unit per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
Issue Name: Bronchoscopy Services
Issue Description: A potential vulnerability may exist if certain bronchoscopy services are billed for more than one unit per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
Issue Name: Blood Transfusions
Issue Description: A potential vulnerability may exist if certain blood transfusion codes are billed for more than one unit per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
Issue Name: Untimed Codes
Issue Description: A potential vulnerability may exist if certain codes are billed for more than one unit. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.
Issue Name: Neulasta
Issue Description: A potential vulnerability may exist if the code J2505 is billed with more than 1 unit per patient per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B inside of this time frame.
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