Medicare MAC/RAC Update

1. Medicare MAC/RAC Update Presented by: HomeTown Health August 12, 2009

2. AGENDA • Connolly RAC Update • Seven Issues Approved by CMS – Dale Gibson • Discussion on Improving Documentation and Coding; Avoid These Issues in the Future - Sherry Milton • 4 Clarifications from CMS Officer – Amy Reese • CAHABA Update – Dale Gibson (attachments) • Questions & Answers

3. Approved Issues by CMS

4. South Carolina Issues The following slides list the approved issues that Connolly has posted that apply to South Carolina only. These issues were posted on August 4th. These issues were posted to South Carolina only. As of July 23rd, Connolly had not worked out a Joint Operating Agreement (JOA) with Cahaba. Connolly stated that they could not begin their work until the JOA was signed.

5. Issue Name: Blood Transfusions Description: CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one (1) per session, regardless of the number of units transfused on that date of service. Provider Types Affected: Outpatient Hospital and Physician. Date of Service: 10/01/2007 Open States Affected: South Carolina Additional Information: Additional information can be found in the following manuals/publications: Federal Register, Volume 67, No.212, page2 Program Memorandum Intermediaries, Transmittal A-01-50, April 12, 2001, page 1 CMS Pub 100-04, Ch. 4, § 231.8

6. Issue Name: Untimed Codes Description: CPT Codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service. Provider Types Affected: Outpatient Hospital and Physician Date of Service: 10/01/2007 Open States Affected: South Carolina Additional Information: Additional information can be found in the following manuals/publications: CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-11 CMS Pub 100-04, Ch. 5, § 20.2

7. Issue Name: IV Hydration Therapy Description: Based on the definition of CPT 90760 (excluding claims modifier-59 ), the maximum number of units should be one (1) per patient per date of service.  Beginning 1.1.09, code 90760 was replaced with code 96360. Provider Types Affected: Outpatient Hospital and Physician. Date of Service: 10/01/2007 Open States Affected: South Carolina Additional Information: Additional information can be found in the following manuals/publications: CMS Pub 100-4 Ch. 12, pages 31-32 CMS Pub 100-20, Transmittal 419, page 7 MLN Matters, MM6349 R/T RC Realease Date 12.19.08, page 4

8. Issue Name: Bronchoscopy Services Description: CPT Codes 31625, 31628 and 31629 should be billed with a maximum number of units of one (1) per patient per date of service (excluding claims with modifier 59)  should only be reported with one unit per date of service. Provider Types Affected: Outpatient Hospital and Physician. Date of Service: 10/01/2007 Open States Affected: South Carolina Additional Information: Additional information can be found on the following website(s): http://www.thoracic.orghttp://healthscience.cypresscollege.edu American Medical Association's (AMA) Current Procedural Terminology (CPT) for 2007, 2008 and 2009.

9. Issue Name: Once in a lifetime procedures Description: By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime. Provider Types Affected: Outpatient Hospital and Physician. Date of Service: 10/01/2007 Open States Affected: South Carolina Additional Information: Additional information can be found on the following manuals/publications: CMS Pub 100-08, Ch. 3, § 3.6 American Medical Association's (AMA) Current Procedural Terminology (CPT) for 2007, 2008 and 2009

10. Issue Name: Pediatric codes exceeding age parameters Description: Newborn/Pediatric CPT codes being applied/billed for patients which exceed the age limit defined by the CPT code. Provider Types Affected: Outpatient Hospital and Physician. Date of Service: 10/01/2007 Open States Affected: South Carolina Additional Information: Additional information can be found on the following manual/publication: American Medical Association's (AMA) Current Procedural Terminology (CPT) for 2007, 2008 and 2009

11. Issue Name: J2505: Injection, Pegfilgrastim, 6 mg. Description: By definition HCPC Code J2505 represents 6 mg per unit. The code should be billed at one (1) unit per patient per date of service. Provider Types Affected: Outpatient Hospital and Physician. Date of Service: 10/01/2007 Open States Affected: South Carolina Additional Information: Additional information can be found in the following manuals/publications: CMS Manual System, Publication 100-04 Medicare Processing Manual, Transmittal 949 (dated May 12, 2006 MLN Matters Number MM5912, Release Date: January 18, 2008 MLN Matters Number MM4380, Release Date: May 12, 2006

12. Clarifications from CMS

13. Q: Is Connolly required to post the approved issues for a certain time period prior to mailing out the demand letters? There is no required waiting period between posting the issues and sending demand or medical record request letters.

14. Q: Does the 1% on complex review include ALL line items including supplies on outpatient procedures? Yes the 1% limit includes all claim lines.

15. Q: Will the initial medical record request from Connolly tell us what the billing or coding issue is? Yes the request will specify why there may be a potential improper payment.

16. Q: Is there a way to confirm that Connolly received our contact information?  Christine may want to follow up but at this point Connolly is not automatically confirming the contact information; providers can assume if they sent it in then Connolly has loaded it. 

17. CAHABA Updates & Attachments

18. Q/A: Report modifier -59 for EKGs performed before or after cardiac catheterization APCs Weekly Monitor, August 7, 2009 Q. An APC edit states that 93005 (electrocardiogram, routine EKG with at least 12 leads; tracing only, without interpretation and report) is a part of comprehensive procedure 93510 (left heart catheterization) and allowed with an appropriate modifier. We always order and perform EKGs before these procedures. Should we add a modifier? Can you direct me to relevant CMS guidance? A. CMS Version 14.2 of the National Correct Coding Initiative (NCCI) Manual states the following: “Cardiac catheterization procedures may require procurement of EKG tracings during the procedure to assess chest pain during catheterization and angioplasty; when performed in this fashion, these EKG tracings are not separately reported. EKGs procured prior to, or after, the procedure may be separately reported with modifier -59.”

19. . Source: MM6395 • As mandated by Section 148 of The Medicare Improvements for Patients and Providers Act (MIPPA), effective for services furnished on or after July 1, 2009, a critical access hospital (CAH) will be paid 101 percent of reasonable cost for outpatient clinical diagnostic laboratory tests even if the patient for whom these services are billed was not physically present in the CAH at the time the specimen is collected. In such cases, the CAH will receive 101 percent of reasonable cost for the outpatient clinical diagnostic laboratory test as long as the patient is an outpatient of the CAH and is receiving services directly from the CAH. For purposes of section 148, the patient is considered to be receiving services directly from the CAH if either one of the following qualifications is met: • The patient receives outpatient services in the CAH on the same day the specimen is collected, or • 2) The specimen is collected by an employee of the CAH. • If the patient is physically present in the CAH or a facility that is provider based to the CAH at the time the specimen is collected, neither of the above two conditions need to be met. • For purposes of payment when a patient is located in a SNF and the CAH employee goes to the SNF to collect a specimen, the CAH will only receive payment at 101 percent of reasonable cost once the patient’s Medicare Part A days have expired. Prior to the patient’s Part A days expiring, payment for the collection of a lab specimen at a skilled nursing facility (SNF) is included in the SNF bundled payment. • For non-patients, tests are still to be billed on the type of bill (TOB) 14x and such claims will be paid based on the clinical laboratory fee schedule. • Here is the link to the MLN Matters article MM6395 . Continue next slide

23. New diagnosis codes for NCD effective 10.01.09

24. New Discharge Status Code of 21

25. Sleep Studies Revised

26. New Codes for UB Under Transfer Codes

27. Billing for ambulance mileage to the tenth of the mile.  Effective 01.01.10

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41. List of Pass Thru DrugsEffective July 1, 2009 Continue next slide