Performant audit updates - 9/3/2015

Performant Recovery posted three new issue in to its CMS list for providers in Region A. (See link for individual state applicability.)

According to the Performant website, the new issues are:

For outpatient hospitals:

• Ranibizumab (Lucentis®) and Aflibercept (Eylea®). Potential incorrect billing occurred for ranibizumab (Lucentis®) and aflibercept (Eylea®) billed in excess of once in 28 days for ranibizumab and monthly (i.e., once in four weeks) for aflibercept, according to FDA labeling. This review will also look at units billed and coding for both drugs.

For physician/non-physician practitioner:

• Ranibizumab (Lucentis®) and Aflibercept (Eylea®). Potential incorrect billing occurred for ranibizumab (Lucentis®) and aflibercept (Eylea®) billed in excess of once in 28 days for ranibizumab and monthly (i.e., once in 4 weeks) for aflibercept, according to FDA labeling. This review will also look at units billed and coding for both drugs.
• Observation Care for Fewer Than 8 Hours-JL. When a patient receives observation care totaling fewer than 8 hours on the same calendar date, the physician shall report Initial Observation Care E/M codes, from CPT code range 99218 – 99220. Payment for CPT codes 99217, 99234, 99235, and/or 99236 billed for observation care for fewer than 8 hours on the same date of service will be denied.