The article previously ran in the Q4 2022 issue ofA2zzz。
我以前曾讨论过参考Medicare(MCR)提供商合规性提示的重要性,并在此列中寻找有关付款率,拒绝原因,编码等不当提示。我最近重新审视了他们与多个多摄影学/睡眠研究有关的合规性技巧,并且没有针对此服务线发布的实质性新更改或提示。作为医疗保健提供者,您应该在为Medicare患者提供服务或物品之前了解Medicare覆盖范围。由于广泛的覆盖范围信息很容易获得,因此Medicare已知道他们希望医疗保健提供者知道其承保范围要求,以避免拒绝付款。
HCPCS and CPT Codes for Testing
This本地报道文章(LCA):计费和编码 - 多渗透学(A56995)provides the most current Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases (ICD)-10 codes that support medical necessity.
背景
根据U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report从2014年1月1日到2015年12月31日,全国医疗保险行政承包商(MAC)支付了独立设施,与医院和医生有关的设施约8亿美元用于选定的多聚会服务(一种用于诊断和评估睡眠障碍的睡眠研究类型)beplay ued客户端。
你必须符合规定Local Coverage Determination (LCD): Polysomnography (L36593)in order to be paid for polysomnography services provided for Medicare patients. Be sure to verify you are referencing the LCD for your service area.
Denial Reasons
Earlier OIG reviews for polysomnography services found that MCR paid for services that did not meet their requirements. They identified payments for services with inappropriate diagnosis codes and/or without the required supporting documentation. Providers with patterns of questionable billing were also noted. As a result of their audit, the OIG estimated MCR overpaid $269 million for polysomnography services during this audit period. These errors occurred because polysomnography services oversight was insufficient to assure providers complied with stated requirements.
防止否认
MCR will cover polysomnography when services meet these criteria:
- 诊所要么隶属于医院,要么由医生控制。在没有直接医师监督的情况下,MCR可能涵盖在睡眠障碍诊所通常进行的诊断测试(因此,MD不需要在现场进行测试),但是在测试过程中必须有政策和程序和足够的超现场。
- 主治医生可以将患者转介到睡眠障碍诊所。要求诊所保留参加医师命令的记录。
- 医学证据证实需要进行诊断测试(例如,医师检查和实验室检查)。这些办公室访问说明和文件也必须保存在睡眠诊所的患者记录中。
MCR不涵盖主体医师进行的早期测试的重复诊断测试,在某种程度上仍然相关,因为根据第1862(a)(1)(a)条,这是不合理的和必要的。Social Security Act。
MCR continues working with MACs to educate providers on properly billing polysomnography services, including meeting the requirements outlined inMedicare计划完整性手册,第5章CPAP服务。
文档要求
MCR确实需要提供给患者进行所有诊断测试(包括多聚会检查)的提供者的订单。多个仪表提供商必须在多摄影术主张中输入订购提供商的名称和国家提供商标识符(NPI)。
仅当患者记录症状,例如病历中的睡眠,睡眠呼吸暂停,阳ot或副传播的症状,才能涵盖多个术语。请注意,未涵盖用于慢性失眠的多症。第70条Medicare Benefit Policy Manual, Chapter 15提供有关覆盖范围指示的详细信息。
I cannot stress enough the importance of also referencing the tips and documentation requirements needed for continuous positive airway pressure (CPAP) devices and accessories. It is not just the durable medical equipment (DME) suppliers or treating practitioners who need to understand these tips. A sleep service program must follow these requirements to ensure that patients can be properly treated for the diagnoses made in our centers.
HCPCS and CPT Codes for PAP
Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of OSA (L33718)provides the most current HCPCS and CPT codes.
背景
According to the2021 Medicare Fee-for-Service (FFS) Supplemental Improper Payment Data, the improper payment rate for CPAP is 30.8%, with a projected improper payment amount of $319 million.
MCR将涵盖DME福利下的CPAP设备和配件(第1861条[S] [6]Social Security Act)。您必须满足National Coverage Determination (NCD): CPAP Therapy for OSA (240.4)。You can reference the policy requirements inLCD L33718。
Denial Reasons
在2021年的报告期间,MCR指出,不足的文件占正气压力设备付款不当的88.6%。没有文件(0.5%),医疗必需品(0.5%),编码不正确(0.1%)和“other” errors(10.3%)导致付款不当。
防止否认
这些医疗保险覆盖范围和付款指南适用于CPAP设备索赔:
- 在睡眠测试之前,患者对治疗从业人员进行了面对面的临床评估,以评估OSA
- 患者经过批准的睡眠测试:
- 通过合格从业者参加的多个多词(PSG)在睡眠实验室中完成
- 带有II型或II型家庭睡眠监控设备的无人值守的家庭睡眠测试(HST)
- 无人看管的HST带有IV型家庭睡眠监控设备,该设备至少测量三个通道
- The sleep test is interpreted by a practitioner who specializes in sleep studies and shows either:
- An Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) greater than, or equal to, 15 events per hour with a minimum of 30 events
- An AHI or RDI is greater than, or equal to, five and less than, or equal to, 14 events per hour with a minimum of 10 events and documentation of:
- 白天过度嗜睡,认知障碍,情绪障碍或失眠
- Hypertension, ischemic heart disease or history of stroke
- When providing the PAP, you must also document that the device’s supplier instructed the patient or their caregiver in the equipment’s proper use and care Continued coverage after 12 weeks depends on practitioner reassessment and documentation of patient therapy regimen adherence and OSA symptom improvement
To Note
MCR does define “apnea” as a cessation of airflow for at least 10 seconds. They define “hypopnea” as an abnormal respiratory event lasting at least 10 seconds with at least 30% reduction in thoracoabdominal movement or airflow and at least 4% oxygen desaturation.
文档要求
为了证明付款是合理的,您必须开会specific requirements when ordering Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)。
对于CPAP设备,MCR确实需要面对面的相遇或书面订单,然后再交付给患者。
资源
Conclusion
It is important to remain updated and compliant with MCR payment standards. It is also important to note that the majority of commercial health insurers follow or reference Medicare guidelines. Establish a culture within your business that promotes prevention of errors and detects and resolves problematic practices to ensure proper documentation.
Despite the ups and downs the sleep industry has experienced recently, I hope that 2022 has been a successful year for you and your organization. Thank you for taking the time to reference AAST, we are very thankful. Here is to a happy and healthy 2023 for you and yours.
Laura Linley,CRTT,RPSGT,FAASbeplay2020网站登录T