We recently received notice that the first RAC has posted their CMS approved audit issues. There seems to be a focus on the proper use of units (details below). Remember, issues posted by any RAC open the door for all RACs to audit these specific areas across the board. This is not to say these are the only areas of focus for the RACs. They will continue to conduct reviews based in part on issues identified in the demonstration project, as well as those highlighted by the OIG. These issues just give them one more area to focus in on.

CMS Approved Audit Issues:

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 can be found in the following manuals/publications:
Federal Register, Volume 67, No.212, page 2
Program Memorandum Intermediaries, Transmittal A-01-50, April 12, 2001, page 1
CMS Pub 100-04, Ch. 4, § 231.8

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 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

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 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 Release Date 12.19.08, page 4

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 can be found on the following website(s):
http://www.thoracic.org/
http://healthscience.cypresscollege.edu/

Please post your comments here or contact the Somerset Health Care Team with questions.