The two claims were denied because the demonstration RACs determined that either a duplicate claim was billed and paid or the physician reported an incorrect number of units for CPT code billed, based on the CPT code descriptor, reporting instructions in the CPT book and/or other CMS local or national policy, according to the article.
Specifically, the RAC demonstration findings examples provided were:
Other services with excessive units — Units billed exceeded the number of units per day based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy. (Improper payment amount (pre-appeal): $6,635,558)
Duplicate claims — Physician billed and was paid for two claims for the same beneficiary, for the same date of service, same CPT code, and same physician. (Improper payment amount (pre-appeal): $1,094,751)
Read the MLN Matters about high-risk vulnerabilities for physician claims (pdf).
Read more about coding and billing challenges:
– SCODI Code Removed From CPT 2011 Codebook
– AMA Issues Update to 2011 CPT Codebooks
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