Edit Name: Exact Duplicate s2

IndianaAIM Resolutions Manual ESC 6653.5

AUDIT NAME: POST OP CARE WITHIN 00 – 90 DAYS OF SURGERY

CLAIM TYPE: / M / HEADER/DETAIL: / Detail
LOCATION: / 22 / OVERRIDEABLE: / Yes
PROGRAMS: /

All

/ ALLOW DENIAL: / Yes
RECYCLE DAY: / 0
DISPOSITION: / M

Paper Claim

/ Suspend
ECS / Suspend
ECS w/attach / CCF
Shadow / Pay
POS / Suspend
Adjustments / Suspend
Special batch / Suspend

AUDIT DESCRIPTION:

This umbrella audit will fail when the same provider who performed surgery bills for post-operative care up to 90 days after surgery.

AUDIT CRITERIA:

If a provider bills an evaluation and management visit, procedure codes 99201-99205, 99211-99215, 99218-99223, 99231-99233, 99238, 99241-99245, 99293, 99294, 99295-99297, 99299, 99301-99303, 99311-99313, 99321-99323, 99331-99333, 99341-99343, or 99351-99353, and payment has been made to the same provider for a surgical procedure with a value of 090 in the "global surgery" field of the Medicare Fee Schedule database for the same recipient within 90 days of the date of service on the claim, fail this audit.

EOB CODES:

6653 - Postoperative medical visits performed within 90 days of surgery are payable only for a surgical complication and if documented as medically indicated. Documentation not present, or does not justify the visit billed.

ARC CODE:

97- Payment is included in the allowance for another service/procedure.

REMARK CODE:

M58- Missing/incomplete/invalid claim information. Resubmit claim after corrections.

METHOD OF CORRECTION:

Route the claim to the Medical Policy Specialist.

Medical Policy Specialist Instructions:

·  Compare the claim to suspense screen and correct any keying errors. If no keying errors:

·  If the claim documents the surgical complication necessitating the visit, override the audit. Surgical complications include, but are not limited to:

1.  Postoperative wound infection requiring specialized treatment.

2.  Elevated temperature above 101 degrees F for two or more consecutive days.

3.  Nausea/vomiting that has persisted more than 24 hours.

4.  Renal failure.

5.  Comatose condition.

6.  Cardiovascular complications.

·  If the procedure paid was billed as surgical care only (modifier 54) by the same provider and the necessity of the visit is documented and justified, override the audit.

·  If visit is related to the original surgery, deny the service with EOB 6653.

·  If no documentation provided on or with the claim or documentation does not justify the visit, deny the service with EOB 6653.

RELATED AUDITS:

ESC 6649

Revised 7/7/2000

Revised 2/28/03

Revised 06/06/05

Revised 10/27/06

Revised 11/02/06