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Medicare Recovery Audit Contractor (RAC) Program >>

Region A Issues

Name	SNF Psychiatric Condition
Number	A000602012
Description	Patients with only a psychiatric condition who are transferred from a psychiatric hospital to a participating SNF are likely to receive only non-covered care. Also, patients whose primary condition/needs are psychiatric in nature often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. (SNFs primarily engaged in treating psychiatric disorders are precluded by law from participating in Medicare.)
Type of Review	Complex
States	CT, DC, DE, MD, ME, MA, NY, PA, MD, NJ, RI, VT, NH
Date Posted	Jan 18, 2013
Provider type	Skilled Nursing Facility
Date of service	Claims having a "claim paid date" which is more than 3 years prior to the ADR date will be excluded.
References	Section 1861(i) of the Social Security Act – Post-Hospital Extended Care Services;42 CFR § 409.30 Basic requirements;42 CFR § 409.31 Level of care requirement;CMS IOM 100-2, Chapter 8, Section 20.1;CMS IOM 100-2, Chapter 8, Section 30.2.3.2;NHIC LCD L29845 - Effective 5/5/2009 for J14 states (ME, MA, NH, RI, VT);NGS Local Medical Policy Article A50641 - Effective 02/01/2011 for J13 states (CT, NY);NGS LCD L26861 - Effective 07/01/2008 through 01/31/2011 for J13 states (CT, NY);

Name	Vitamin D Assay Testing
Number	A000812012
Description	Potential incorrect billing of Vitamin D Assay Tests not supported by medical necessity [NGS LCD L29510 (A49254) and Novitas LCD L30273].
Type of Review	Automated Review
States	NY, PA, MD, DC, NJ
Date Posted	June 4, 2012
Provider type	Skilled Nursing Facility
Date of service	Claims having a "claim paid date" which is more than 3 years prior to the ADR date will be excluded.
References	Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A);Title XVIII of the Social Security Act (SSA): Section 1833(e);NGS LCD L29510 effective for services on or after 9/1/2009;NGS Article A49254, related to LCD L29510, effective for services on or after 9/1/2009;NSI LCD L30273, effective for services on or after 10/28/2009;

Name	Ambulatory Surgery Centers (ASC) / Skilled Nursing Facility (SNF) Consolidated Billing
Number	A000762012
Description	Under SNF consolidated billing, the SNF is responsible for the entire package of services that its residents receive during the course of a Part A stay with some exceptions. Potential billing error exists when an ASC bills Medicare Part B directly instead of SNF for reimbursement which also increases out-of-pocket liability for beneficaries.
Type of Review	Automated Review
States	CT, DC, DE, MD, NJ, NY, PA
Date Posted	June 5, 2012
Provider type	Ambulatory Surgery Center
Date of service	Claims having a "claim paid date" which is more than 3 years prior to the ADR date will be excluded.
References	Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) and (a)(18) SNF Consolidated Billing;Medicare Claims Processing Manual, IOM 100-04, Chapter 6, SNF Consolidated Billing;OIG TDL A-01-09-00521, Payments for ASC Services Provided to Beneficiaries in SNF Part A Stays;MLN Matters Number MM3592, Implemented 1/24/05;CMS TDL 101211, OIG Reports sent to All Recovery Auditors;

Name	CT Scans, Trunk and Extremities, Incorrect Billing
Description	Potential incorrect billing of CT scans not supported by medical necessity (NGS LCD 28516 (A48015))
Type of Review	Automated Review
States	NY
Date Posted	April 2, 2012
Provider type	Skilled Nursing Facility
Date of service	Claims having a "claim paid date" which is more than 3 years prior to the ADR date will be excluded.
References	Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A);Medicare National Coverage Determination Manual, 100-03, Chapter 1, Part 4, 220.1;NGS LCD L28516 (A48015); effective 1/1/2009 to 11/14/2011 for Connecticut and New York;NGS Article A48015, related to LCD L28516;

Name	CT Scans, Head and Neck, Incorrect Billing
Description	Potential incorrect billing of CT scans not supported by medical necessity (NGS LCD 28516 (A48015))
Type of Review	Automated Review
States	NY
Date Posted	April 2, 2012
Provider type	Skilled Nursing Facility
Date of service	Claims having a "claim paid date" which is more than 3 years prior to the ADR date will be excluded.
References	Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A);Medicare National Coverage Determination Manual, 100-03, Chapter 1, Part 4, 220.1;NGS LCD L28516 (A48015); effective 1/1/2009 to 11/14/2011 for Connecticut and New York; effective 1/1/2009 to 06/05/2009 for Vermont and New Hampshire; effective 1/1/2009 to 05/15/2009 for Maine and Massachusetts;NGS Article A48015, related to LCD L28516;

Name	Untimed Codes
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
Type of Review	Automated Review
States	CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Provider type	Physician (Carrier) / Outpatient Hospital
Date of service	October 1, 2007-Present
References	IOM 100-04, Chapter 5, Section 20.2; IOM 100-04, Transmittal 1019, dated 8.3.06, pages 7-11

Name	DMEPOS while Inpatient (B4034-B9999; E0100-E9999; K0001-K0899)
Description	A supplier may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two (2) days prior to the patient's anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient's home). The item must be for subsequent use in the patient's home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.
Type of Review	Automated
States	NY, NH, MA, MD, ME, VT, PA, DE, DC, RI, CT, NJ
Provider type	DME
Date of service	October 1, 2007 - Present
References	Social Security Act, Volume I, Title XVIII (Health Insurance for the Aged and Disabled), Section 1834 (Special Payment Rules for Particular Items and Services), Subsections (2)(B); (3)(A); (5)(A); (7)(A)(i)(1); (7)(C)(ii)(1);CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50. 110.1 and 120;CMS Internet-Only Manuals (IOMS), Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 40.2;CMS Internet-Only Manuals (IOMs), Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, Section 180.2;CMS Internet-Only Manuals (IOMs) Publication 100-03, Medicare National Coverage Determinations Manual Chapter 1. Part 4, Sections 240.2, 240, 4, 280.1, 280.2, 280.3, 280.6 and 280.7;CMS Internet-Only Manuals (IOMs) Publication 100-04, Medicare Claims Processing Manual, Chapter 20-Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Sections 10.2, 30.6, 100.2.2 and 110.3.;CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 4. Section 4.26.2.;CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 5. Section 5.2.3;CMS NHIC, Corporation LCD for Jurisdiction A L5049 LCD for Hospital Beds and Accessories, effective 10/01/1993, revised 02/04/2011;

Name	Duplicate Claims - Part B
Description	Providers should not bill duplicate claims. Therefore, an issue may exist when duplicate services are billed and reimbursed under Medicare Part B.
Type of Review	Automated Review for Overpayments
states	CT, DC, DE, MD, NJ, NY, PA
Provider type	Physician (Carrier) / Outpatient Hospital
Date of service	October 1, 2007 - Present
References	IOM 100-04 Chapter 1, Section 120;

Name	National Correct Coding Initiative - Part B
Description	A provider may not bill a Column II code when billed by the same provider and same date of service as a Column I code. Therefore, an issue may exist when Column II codes are billed and reimbursed under Medicare Part B in this manner.
Type of Review	Automated Review for Overpayments
states	CT, DC, DE, MD, NJ, NY, PA
Provider type	Physician (Carrier) / Outpatient Hospital
Date of service	October 1, 2007 - Present
References	IOM 100-04 Chapter 12, Section 30; IOM 100-04 Chapter 23, Section 20.9;

Name	Add On Codes
Description	Claims overpaid for add-on codes when the required primary procedure either was not billed or was not paid for other reasons. Therefore, an issue may exist when these codes are billed and reimbursed under Medicare Part B in this manner.
Type of Review	Automated Review for Overpayments
States	CT, DC, DE, MD, NJ, NY, PA
Provider type	Physician (Carrier) / Outpatient Hospital
Date of service	October 1, 2007 - Present
References	IOM 100-04 Chapter 12, Section 30;

Name	Clinical Social Worker (CSW)
Description	CSW services rendered during an inpatient acute care or skilled nursing facility stay are not separately payable under Medicare Part B, instead they are included in the facility’s Prospective Payment System (PPS) payment. CSW providers are expected to render services under arrangement with the facility. Therefore, an issue may exist when a beneficiary received CSW services during an inpatient stay, which have been billed and reimbursed under Medicare Part B.
Type of Review	Automated Review
States	CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Provider type
Date of service	October 1, 2007 to Present
References	Medicare Benefit Policy Manual: Pub100-2, Ch15, § 170; CMS MedLearn Matters Article #: SE0439.;

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