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Industry News: Puerto Rico

Reopening requests for certain claims to be reprocessed under the Affordable Care Act no longer being accepted
Friday, July 29, 2011

In May 2011, First Coast Service Options (FCSO) began accepting fax requests for reopenings of claims with dates of service in January-May 2010 to be reprocessed under the Affordable Care Act (ACA). Since that time, mass adjustments have been executed that automatically reprocess claims where the billed amount was greater than the new (post-ACA) allowances. To reduce workloads and costs associated with manually reprocessing faxed requests, CMS has authorized contractors to stop performing manual reopening of those claims that are scheduled to be mass-adjusted.

CERT errors regarding complete blood count (CBC) services
Tuesday, March 01, 2011

First Coast Service Options has seen an increase in the number of Comprehensive Error Rate Testing (CERT) errors related to CPT codes 85025 and 85027. Based on review of documentation by the CERT review contractor, findings have revealed that this service is incorrectly coded.

These CPT codes are defined as:

• CPT 85025 -- complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count.
• CPT 85027 -- complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count)

Recommendations regarding the development of a model compliance plan for clinical laboratories
Monday, November 22, 2010

Medicare will only pay for tests that meet Medicare’s reasonable and necessary guidelines. Medicare may deny payment for a test that the physician believes is appropriate but does not meet Medicare’s definition of “medical necessity.”

The Office of the Inspector General (OIG) recommends that laboratories and laboratory companies take the following precautions to help ensure that requirements for medical necessity are met:

Provider Data Summary Report
Wednesday, September 01, 2010

All members of the jurisdiction 9 (J9) provider community (Florida, Puerto Rico, and the U.S. Virgin Islands) can take advantage of the Provider Data Summary report (PDS) portal to help improve the accuracy and efficiency of their Medicare billing operations.

PDS reports help providers identify and correct recurring billing issues:

84295: Serum sodium -- update to previous billing instructions 82435: Chloride; blood
Friday, June 25, 2010

An article published in the January 2010 Medicare B Update (page 51) of the publication may have led providers to a misunderstanding regarding the correct use of modifier CB (Service ordered by a renal dialysis facility [RDF] physician as part of the ESRD (end-stage renal disease) beneficiary’s dialysis benefit, is not part of the composite rate, and is separately reimbursable).

Signature guidelines -- 20-day timeframe for additional documentation requests
Thursday, May 27, 2010

Medicare claim review contractors, including the comprehensive error rate testing (CERT) contractors and recovery audit contractors, are tasked with measuring, detecting, and correcting improper payments in the Medicare fee-for-service (FFS) program. These contractors review claims and medical documentation submitted by providers.

Signature requirements -- guidelines for authentication of Medicare services
Monday, May 03, 2010

CMS requires that any Medicare service provided or ordered must be authenticated by the author -- the one who provided or ordered that service. Authentication may be accomplished through the provision of a hand-written or an electronic signature; however, stamp signatures are unacceptable.

84295: Serum sodium
Tuesday, February 02, 2010

First Coast Service Options Inc. (FCSO) has been made aware of an issue regarding providers receiving denials when billing CPT code 84295 (Sodium; serum, plasma or whole blood) and ICD-9-CM code 585.6 (End-stage renal disease) for hemodialysis patients when modifiers CB and CF and several other modifiers identified for the automated multichannel chemistry tests (AMCC) were appended that noted the service rendered were outside the composite rate.

Complete blood count with or without automated differential WBC count
Wednesday, December 02, 2009

First Coast Options- MAC for Jurisdiction 9, which includes Puerto Rico, the U.S. Virgin Islands and Florida

Medicare pays for clinical laboratory services that are medically reasonable and necessary, ordered by a physician, and used by the physician in the treatment of the patient.