0168-Denial of the Professional Component for Previously-Denied Facility Claims for Medically Unnecessary Endomyocardial Biopsies and Right Heart Catheterizations Billed as Separate Procedures
When a procedure is performed, there are sometimes two claims submitted for the same code. The facility’s claim for procedure is submitted and the surgeon’s claim for the procedure is also submitted. The documentation for this procedure is the same as is the CPT/ HCPCS code billed. If, after complex review, there is a denial of the procedure code on the facility claim that is upheld, recover the physician claim for that same code automatically.
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986- Good Cause for Reopening
5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §126.96.36.199- No Response or Insufficient Response to Additional Documentation Requests
6. 42 CFR §411.15(k)(1), Particular services excluded from coverage (k) Any services that are not reasonable and necessary for one of the following purposes: (1) For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member
7. 42 CFR §424.5(a)(6), Basic conditions (a) As a basis for Medicare payment, the following conditions must be met: (6) Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
8. Medicare Benefit Policy Manual, Chapter 16 - General Exclusions from Coverage §20- services not reasonable and necessary
9. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.2.3- Requesting Additional Documentation During Prepayment and Post payment Review