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CRIP, Section 3-2
Certified Revenue Integrity Professional - Screening Services
| Question | Answer |
|---|---|
| List requirements for coverage for Pap Smear Screening: | - order & collect by pract. auth under state law. - no same test in past 2 yrs - screening dx on claim - pt of childbearing age & exam has shown presence of cervical/vaginal cancer or abnormalities during past 3 yrs. - high risk of cancer |
| What are the high factors that can contribute to cervical cancer? | - sexual activity age 16 yrs or younger - more than 5 partners in a lifetime - hX of any type of STD - having less than 3 negative or any positive pap smears in past 7 years |
| What is the high risk factor that can contribute to vaginal cancer? | - daughters of women who took diethylstilbestrol (DES) during pregnancy. |
| A Pelvic Examination, with or without specimen collection or smears and cultures, should include at least 7 of 11 of the following elements: | - breast exam - digital rectal exam - external genitalia - urethral meatus - urethra - bladder - vagina - cervix - uterus - check for organomegaly or nodularity - anus and perineum |
| When is it possible to receive reimbursement from CMS for a screen pelvic exam more frequently - and what is the frequency allowed. | Once every 35 months. Only if there is evidence that the woman is at high risk. |
| What is PSA Screening and why is it done, what does it entail and how often is it allowed? | Prostate Specific Antigen Screening For early detection of prostate cancer A screening digital rectal exam and a screening PSA blood test Once every 12 mos for men 50 and over |
| Colorectal cancer Screening as defined by CMS: | - fecal-occult blood test (FOBT) - every year - Flexible sigmoidoscopy - every 4 yrs - colonoscopy - every 10 yrs - barium enema (BA) - only as alternative to cover a screening flexible sigmoidoscopy |
| Vaccines: Pneumococcal (Pneumonia) Vaccine | - MC no longer requires physician's order to receive, it can be administered at the beneficiary's request - usually only administered once in a lifetime - Revaccination can be administered for high risk individuals |
| What are the high risk factors for Pneumonia? | - 65 years or older - immunocompetent adult at increased of complications due to chronic illness - any individual with a compromised immune system - practitioner should not require immunization records or have to review hX, can rely on pt's verbal hX |
| Influenza (Flu) Vaccine | Once per flu season. no physician order required. |
| Hepatitis B Vaccine | Covered if ordered by a doctor. Available to beneficiaries who are considered at high or intermediate risk of contracting Hep B. Per CMS, not eligible for this benefit if currently positive for antibodies for Hep B. |
| Injections and Infusions: Definitions and types of service | IV Infusion - lasts more than 15 min thru a catheter, venous access device or IV access line. Must have documented stop and start times. IV Push (IVP) - administered from a syringe and pushed into the venous access site. |
| When should IV/IVP administration charges or Keep Vein Open (KVO) charges be reported? | Never |
| Injection and Infusion charges: Initial Service charge: | - svc that best describes reason for encounter. Only 1 initial svc code reported for DOS unless an addt'l initial svc is med nec due to combination of drugs/substance or pt returned for separate, med nec encounter on same day. |
| Injection and Infusion charges: Initial Service Charge - multiple on same DOS: | - If IV and IVP on same DOS, IV will be initial svc. - If both chemo and non-chemo on same DOS, chemo will be initial svc. - hydration will not be considered an initial svc if administration of substances by an IV are performed in same visit. |
| Injection and Infusion charges: Sequential Administration: | When multiple drugs are infused back to back. Must be a different drug thru same IV access. Must be a reason to do back to back vs. concurrent. Subsequent administration of substance/drug occrs during a distinct or separate encounter on same DOS. |
| Injection and Infusion charges: Concurrent Administration: | When multiple medications (not hydration fluids) are infused simultaneously thru separate bags but same IV line. Not billable for multiple drugs within the same bag, can only be billed once per encounter. |
| Injection and Infusion: 15- minute rule: | Established by AMA and CMS, states that any IV infusion lasting 15 minutes or less should be billed as an IVP injection and not as an IV Infusion |
| Injection and Infusion: 30-minute rule: | hydration therapy shld have a min of 31 min recorded b4 it can be considered billable. dox shld show med nec & incl rate of infusion. Shld not be integral part of other svc. If 31 min or more btx 2 IVPs of same drug, an addt'l unit of svc can be billed |
| Injection and Infusion: 60-minute rule: | Initial hour reported for infusions includes infusions lasting > 16 min but not exceeding 90 min. IV exceeding 60 but less than 90 min shld only be billed 1 code. report CPT signifying each additional hour for over 91 min. |
| Hydration vs. Infusion: | Relies on physician orders: ex - If physician ordered hydration to include electrolytes, the svc billed is hydration. If order is potassium chloride infusion, codes for therapeutic drug administration shld be reported. |
| Pharmacy: what items in the pharmacy CDM should be reviewed/audited frequently? | Rev code assigned for UB NDC, if on the CDM Assign appropr HCPCS code-status ind K codes are sep reimb by MC drug divisors to equate to appropr units on UB avg wholesale price of pharma items Constant verifi that compound drugs set up & chrgs appropr |
| Pharmacy: Single dose vial: | S- do not contain antimicrobial preservative - must be used within 6 hours - may be billed for dose administered plus any wastage. Must use JW modifier only on the discarded amt, which is billed on a separate line. |
| Pharmacy: Multi-dose vial: | - Contains a preservative - May be used up to 28 days - May only be billed for the dose administered |
| Pharmacy: Drug Divisors or Multipliers | Most drug HCPCS codes are based on the smallest dose possible, so HCPCS code must be entered w/ measurement and then # of units should be what is administered. |
| What must a valid pharmacy order include? | - Pt name - name of pharmaceutical including frequency, route and dosage - duration or quantity of infusion, if ordered - reason for order - drug specific instructions - name and signature of individual prescribing date and time order was written |
| What must be included in the pharmacy documentation? | level of complexity prov (chemo/hydration, etc) name of meds admin loc or access site route of admin start and stop times/med dose admin & any waste flushing of lines dox of complications chnges to phys orders removal of IV & when therapy disc |
| Self administered drugs: | provided on OP basis, not covered by MC - creams & ointments - tablets/capsules orally - suppositories injection eg: insulin - inhalation drugs Unless an integral part of the proc or is covered by statute (eg: anti-cancer oral drugs) it is PR. |
| CMS rule on Coverage of Injectable Drugs | unless it appears on the MAC (MC Administrative Contractor) "SAD Exclusion" list, it is considered non covered and the administration charge is also non covered. ABN is not required but discussion is highly recommended |
| What does NDC stand for and explain: | National Drug Code By CMS maintain by FDA, ID drugs that cld be reimbursable. 3 components 1 assign by FDA, Id's vendor who made, packaged and distributed 2 ""manufacturer - product info - generic name, dose and strength. 3."" manu - size of product |
| How many digits are in an NDC? | 10 digits on package, configured 4-4-2, 5-3-2 or 5-4-1 (for components of code) Must be converted to an 11 digit code for billing by inserting a leading zero and is always reported on the bill as 5-4-2 with the zero at the beginning. No hyphens on claim. |
| Non Routine Dialysis Treatments (unscheduled or Emergency Dialysis Treatments): When are they reimbursable in OP hospital setting that is not certified as an ESRD facility? | -following/ in connection w/ a dialysis related proc/blood transfusion -following a trtmt for an unrelated med emergency -emergency dialysis is needed for ESRD pts who would have to be admitted as IP in order to the hospital to receive pmt. |
| How does the non-ESRD certified hospital OP facility bill MC for non routine dialysis treatments? | Use HCPCS code G0257 "unscheduled or emergency dialysis trtmt for an ESRD pt in a hospital OP dept that is not certified as an ESRD facility. Only reported on TOB 13X or 85X |
| What is HCPCS code 90935 and when can it be billed? | "Hemodialysis proc w/ single physician eval." only if: 1. pt is IP w/ or w/o ESRD and has Part B cov but not Part A. Must use TOB 12X or 85X. 2. hosp OP doesn't have ESRD and is receiving hemodialysis in the hosp OP dept. Use TOB 12X, 13X or 85X |
| What is CPT code 90945 and how is it billed? | Dialysis procedure other than hemodialysis w/ a single physician eval. May be billed by a hospital paid under OPPS or CAH method I or method II on TOB 12X, 13X or 85X |
| What is Epogen? | Erythropoietin Stimulating Agent (ESA) a pharma to treat a low # of red blood cells caused by chronic kidney disease in pts who are on dialysis to lessen the need for red blood cell transfusions. Sometimes administered when emergency dialysis is needed. |
| Hemoglobin and Hematocrit readings listed on bill for dialysis patients: | Hemoglobin - reported before start of billing pd on UB-04 w/ a value code of 48. if no reading available, report 99.99 Hemotocrit reading must be obtained prior to dialysis trtmt & reported on UB-04 w/ value code of 49 |
| What revenue codes are used to report the administration of Epogen? | 0634 - Epogen administrations less than 10,000 units 0635 - Epogen administrations10,000 units or greater |
| If more than 10,000 units of Epogen are administered, what are the documentation requirements per CMS? | FE Deficiency Cond: infection, inflammation, malignancies unrecognized blood loss Bone Marrow displasia or refractory anemia for reason than renal dis B12/folic acid def Marrow repl w/ other tissue Wt, dose requ, hX amts given & hematocrit resp |
| How would you code Epogen administered to non ESRD patients? | HCPCS code J0881 or J0885 with a modifier: EA: Anemia, chemo-induced EB - Anemia, radio-induced EC - Anemia, non-chemo/radio |
Created by:
Amy17349
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