Approved RAC Audit Issues: August 4, 2009 E-mail
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Tuesday, 04 August 2009 17:41

First RAC Audit Issues Appear

CMS has evidently approved the first issues for RAC audits by Connolly Healthcare. Seven specific issues are now listed on the Connolly Healthcare RAC website. Connolly is responsible for Region C, but the issues have so far only been approved for the state of South Carolina.

States Affected: South Carolina

Provider Types Affected: Outpatient Hospital and Physician.

Below are the issues listed with links to reference documents:

Issue Name Description Reference Materials
Blood Transfusions

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.

Federal Register, Volume 67, No.212, page2
Untimed Codes

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.

IV Hydration Therapy

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.

Bronchoscopy Services

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.

http://www.thoracic.org
http://healthscience.cypresscollege.edu
Once in a lifetime procedures

By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime.

Pediatric codes exceeding age parameters

Newborn/Pediatric CPT codes being applied/billed for patients which exceed the age limit defined by the CPT code.

American Medical Association's (AMA) Current Procedural Terminology (CPT) for 2007, 2008 and 2009.

J2505: Injection, Pegfilgrastim, 6 mg.

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.

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

 

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