Connolly Healthcare will be targeting physicians and outpatient hospitals after gaining CMS approval to investigate seven specific issues. However, the recovery audit contractor (RAC) says only South Carolina is affected.
Connolly is the first RAC to release its CMS-approved issues publicly. Below is a list of those issues, but look for more coverage of this news in the next Part B News issue and on www.partbnews.com.
1. Blood transfusions (excluding claims with any modifiers) should be billed as one per session regardless of the number of units transfused on that date of service. CPT codes targeted:
a. 36430 (blood transfusion service, $36.07)
b. 36440 (blood push transfusion, 2 yr or older, $50.85)
c. 36450 (blood exchange/transfuse, newborn, $116.86)
d. 36455 (blood exchange/transfuse, non-newborn, $126.59)
2. Untimed codes (excluding modifiers KX [specific required documentation on file], and 59 [distinct medical service]) where the procedure is not defined by a specific timeframe. The provider should have entered a one in the units billed column per date of service.
3. IV Hydration therapy based on definition of 90760 (excluding claims modifier 59), the maximum number of units should be one per patient per date of service. NOTE: Beginning Jan. 1, code 90760 was replaced with 96360 (IV infusion, hydration initial 31 minutes to 1 hour, $56.62).
4. Bronchoscopy services should be billed with a maximum number of units of one per date of service (excluding claims with modifier 59), and should only be reported with one unit per date of service.
a. 31625 (bronchoscopy w/biopsy, $324.60)
b. 31628-31629 (bronchoscopy/lung bx, each)
5. Once in a lifetime procedures by virtue of the description of the CPT code, these codes can be performed only once per patient lifetime.
6. Pediatric codes exceeding age parameters, newborn/pediatric CPT codes being applied/billed for patients exceeding the age limit defined by the code.
7. J2505 (injection, Pegfilgrastim, 6 mg) the code should be billed at one unit per patient per date of service.