Medicare MAC

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

2. 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 CMS Update � Dale Gibson (attachments) WPS/CAHABA Update � Dale - Kathy Introduction to Corrie Jarrett, RAC Project Coordinator Questions & Answers

3. Approved Issues by CMS

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.org http://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

17. CAHABA Updates & Attachments

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25. RECENT Widespread Probe Review Results � AL � Part A � Review of CPT 64475, 64476 and 64470, 64472 (Injection, Anesthetic Agent and/or Steroid, Paravertebral Facet Joint of Facet Joint Nerve) Agent and/or Steroid, Paravertebral Facet Joint of Facet Joint Nerve)  Alabama Medical Review Part A has recently completed the prepay probe review of CPT 64475, 64476 and 64470, 64472.� The claims were randomly selected across the provider community billing this service that met the parameters of the edit. The edit numbers for this review were 5165V and 5166V.� The focus of the review was on the correct billing of this CPT code. Review of the claims submitted indicated the following: Several claims were submitted without the appropriate modifier to indicate unilateral or bilateral injections.� The documentation on the procedure note on several claims did not support that the CPT submitted on the claim was provided in addition to another procedure performed.� Multiple units of 77003 were billed on the claim and this code should be reported once per spinal region.

26. WHY THE WIDESPREAD PROBE? THE OIG

27. WHY THE WIDESPREAD PROBE? THE OIG

28. New diagnosis codes for NCD effective 10.01.09

29. New Discharge Status Code of 21

30. Sleep Studies Revised

31. New Codes for UB Under Transfer Codes

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

33. Separately Payable Drug List

46. List of Pass Thru DrugsEffective July 1, 2009