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The low-hanging fruit for the RACs in their first round of automated reviews are most assuredly in the “excessive unit audits” that are accomplished through data mining and do not require medical records.

While excessive unit audits are nothing new for many payer and OIG audits, both HDI and Connolly now are focusing on the excessive unit audits for these areas:


  • Bronchoscopy: Providers should bill bronchoscopy services with a maximum of one unit per patient, per date of service.
  • IV Hydration: Providers should bill IV hydration with a maximum of one unit per patient, per date of service.
  • Untimed Codes: When reporting service units for untimed codes (excluding modifiers -KX and -59), for which a procedure is not defined by a specific time frame, the provider should enter a “1” in the units billed column per each date of service.
  • Blood Transfusions: Providers should bill blood transfusions with a maximum of one unit per patient, per date of service.

In this article, we’ll examine the issue of blood transfusions with excessive units.

The Issue:
CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one (1) per session regardless of the number of units transfused on that date of service.

Under OPPS, hospital outpatient departments must use CPT codes to report most procedures on claim forms. Providers may find one of the following CPT codes relevant for reporting blood transfusion services:


CPT Code* Description
36430 Transfusion, blood or blood components
36440 Push transfusion, blood, 2 years or under
36450 Exchange transfusion, blood, newborn
36455 Exchange transfusion, blood, other than newborn
36460 Transfusion, intrauterine, fetal


Blood Billing Guidelines

On March 4, 2005, the Centers for Medicare and Medicaid Services (CMS) issued long-awaited Medicare blood billing guidelines for hospital outpatient departments. As in the original 2001 guidelines, the new guidelines also stated that hospital outpatient departments may bill Medicare for transfusion procedures only once per day, regardless of the number of units or different types of blood products transfused. (Source: American Red Cross – Comprehensive Guide to Billing and Reimbursement for Blood, Blood Products, and Related Services (2007 Update))

Do your own data mining in the interim BEFORE the automated audits hit in order to identify your vulnerability in this area.

During the demonstration project, the takeback was not large ($2.4 million as of November 2006; source: CMS – Medicare RACs – FY 2006 Status Document), but auditing excessive blood transfusion units IS a target of other federal and state investigations. This will continue to be a hot-button issue in benefit integrity moving forward, as evidenced by these cases in recent years:


  • Lahey Clinic admits to improperly billing Medicare. Anonymous. The Sun. Lowell, Mass.: Apr 22, 2009.
  • Hartford Hospital Agrees To Reimburse Medicare. Hilary Waldman. McClatchy – Tribune Business News. Washington: May 28, 2008.
  • Yale-New Haven Hospital transferred $3.8 million to the U.S. attorney’s office Friday. Mary OLeary. New Haven Register. New Haven, Conn.: Mar 8, 2008. p. 1.


About the Author

Carla Engle, MBA, is a product manger for MediRegs, a Wolters Kluwer company. Her background includes more than 20 years in hospital and physician practice operations, particularly in reimbursement and billing functions. Prior to joining Wolters Kluwer recently, she was the vice president of compliance for a national revenue cycle solutions company and prior to that was in the reimbursement Training Department with HCA.  For several years she headed up the Part A Fraud Investigation Unit for a CMS Program Safeguard Contractor (PSC) where she was successful in the prosecution of several national cases. In her revenue cycle compliance capacity, she worked with a number of clients in California and Florida with Recovery Audit Contractors (RACs) in setting up processes and appeals.

Contact the Author


Additional information about blood transfusion billing can be found in the following manuals/publications:

  • Federal Register, Volume 67, No.212, Page 2
  • Program Memorandum Intermediaries, Transmittal A-01-50, April 12, 2001, Page 1
  • CMS Pub 100-04, Ch. 4, § 231.8


HDI’s website:  http://racinfo.healthdatainsights.com/

Connolly’s website: http://www.connollyhealthcare.com/RAC/Pages/cms_RAC_Program.aspx

* CPT codes copyright 2006 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use.


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