Recent Comprehensive Error Rate Testing (CERT) Errors and Data Analysis Findings

Incorrect Coding

TOB 13X

• HCPCS Code 85025 is for a Complete Blood Count (CBC) with a differential White Blood Count (WBC). Errors have been received for incorrect coding when a review of the medical documentation indicates that the physician ordered HCPCS Code 85027, Complete Blood Count (CBC).
• HCPCS Code 81000 is for the billing of Urinalysis with Microscopy. A review of data indicates that providers may be billing HCPCS Code 81000 when a physician order indicates Urinalysis without Microscopy which should be billed with HCPCS Code 81002.

Billing For An Unallowable Service

TOB 72X

• HCPCS Code J3490 is for the billing of an unclassified drug. An error has been received for the billing of an unallowable service. The medical documentation submitted described a screening test for Tuberculosis. The order was written for a test once per year. A screening test is not covered by Medicare. It appears that HCPCS Code 86580 is a more specific code for the billing of a Tuberculosis skin test. Documentation should indicate the medical necessity for the test being performed and not yearly screening.

Unbundling

TOB 85X

• HCPCS Code 82272 is for the billing of Occult Blood Feces, 1-3 tests. An error has been received for unbundling. The claim had another line billed with HCPCS Code 82272 with a modifier 91 indicating a repeat clinical diagnostic laboratory test. The medical documentation submitted included orders for “Hemoccult x 2” and the results of 2 Hemoccults. The definition of HCPCS Code 82272 includes up to 3 results; therefore, the repeat billing is unnecessary.

Page last updated: April 27, 2010

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