All Entries in the "RACS" Category
RAC issues for region C released
Connolly Healthcare, the RAC for region C, has now posted issues for review in Florida, including one issue not yet approved for other locations. Similar to South Carolina, RACs may now audit providers in Florida on the following six issues:
- Untimed codes
- IV hydration therapy
- Once in a lifetime procedures
- Pediatric codes exceeding age parameters
- J2505: Injection, Pegfilgrastim, 6 mg
- Blood transfusion
Note that CMS has not approved bronchoscopy services audits at this time for Florida providers. However, CMS has approved the following new issue:
Clinical social worker (CSW) services. CSW services rendered during an inpatient hospital stay are not separately payable under Medicare Part B; they are included in the facility’s prospective payment system (PPS) payment. CSW providers are expected to seek reimbursement from the facility.
Connolly has not yet posted approved issues for other states and territories in the region, including Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, Tennessee, Texas, West Virginia, as well as Puerto Rico and the U.S. Virgin Islands.
Editor’s Note: For more information on all things RAC visit The RAC Report.
RAC: Complex reviews to arrive as soon as August
Those who haven’t seen the latest e-mail news blast, I thought I’d post it again here.
by Andrea Kraynak, CPC-A
CMS released further information June 24 on its RAC Web site letting healthcare providers know when they can expect RACs to begin auditing. The new “CMS RAC Review Phase-in Strategy,” details different types of reviews and dates CMS anticipates the reviews will begin in various areas of the country.
The new information is consistent with CMS’ previous indications that some providers may begin to undergo automated review this month.
According to the CMS, the earliest possible dates for RAC reviews in yellow and green states are:
- June 2009—Automated reviews of black and white issues
- August or September 2009—Complex reviews for DRG validation
- August or September 2009—Complex review for coding errors
- Fiscal year 2010, which begins October 1, 2009—Complex reviews for durable medical equipment (DME) medical necessity
- Calendar year 2010—Complex reviews for medical necessity
The earliest possible dates for reviews in blue states generally fall a bit later:
- August 2009—Automated reviews of black and white issues
- October or November 2009—Complex reviews for DRG validation
- October or November 2009—Complex review for coding errors
- Fiscal year 2010—Complex reviews for DME medical necessity
- Calendar year 2010—Complex reviews for medical necessity
CMS also reaffirmed that before RACs actively begin auditing in a particular state, outreach educational sessions must occur in that area.
Although the schedule calls for automated reviews as early as this month, any issue a RAC reviews must be vetted through the CMS’ “Issue Review Board.” In addition, RACs must post the approved issues to their Web sites before the reviews can begin.
“Providers should check their RAC’s Web site often for any newly approved issues for review to anticipate their vulnerability to reviews and take backs,” says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.
Even though CMS has delayed the rollout of certain types of complex reviews, providers shouldn’t ease off on their RAC preparation activities.
“Use the time wisely to continue performing your own internal vulnerability audits and ensure that all of your policies and procedures are up-to-date. Consider this a little extra time to get your facility ready for those appeals,” says Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital of Southern California.
Note: Twist and Hoy will be speaking at the upcoming conference, “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors,” which will be held in Atlanta this October. Twist will also be featured in the July 21 HCPro audio conference, Medicare Appeals: Practical and Compliant Procedures for Overturning Denials.
AHA quotes CMS ‘No RAC med-neccessity reviews till next year’
According to a May 28 article in the AHA News Now newsletter CDI specialists need not worry about medical necessity reviews from Recovery Audit Contractors at least until next year.
During the three-year RAC demonstration, 32% of all claims denials were for medical necessity. A CMS-study however showed the California demonstration RAC had a 40% error rate when it examined medical necessity denials of inpatient rehabilitation facility claims, the AHA article states.
AHA’s senior associate director for policy Rochelle Archuleta says the CMS analysis validated the healthcare industries concerns about RAC auditor’s ability to interpret physician judgment.
Alphabet soup: Five CMS acronyms every CDI should know
Okay, I know there are ton of other acronyms that clinical documentation improvement specialists
Tasty!
need to know, not the least of which include CC, MCC, DRG, POA, HAC, CHF, CKD, ARF, (don’t forget about the biggy—CMS!) and so on. . .
On the tail of my last post regarding recovery audit contractors I noticed a number of other data collection government groups associated with CMS that clinical documentation folks may or may not be aware of. I thought maybe you’d find a quick rundown of these acronyms helpful. A note of caution, however, I pulled the definitions from various helpful public Web sites so consider these more like Grandma’s recipes than the combination to the safe that hides the list of well-guarded Campbell’s ingredients.
- Quality Improvement Organizations (QIO): The mission of the QIO is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. In August 2008, work began on the QIO Program’s 9th Statement of Work, which extends through July 31, 2011.
- Comprehensive Error Rate Testing (CERT): One of two CMS programs to monitor and report Medicare payment inaccuracies. CERT measures the error rate for claims submitted to Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs).
- Hospital Payment Monitoring Program (HPMP): The second of two CMS programs to monitor and report Medicare payment inaccuracies.The HPMP measures the error rate for the Quality Improvement Organizations (QIOs).
- Program for Evaluating Payment Patterns Electronic Report (PEPPER): An electronic data report containing hospital-specific data for a number of target areas specific Diagnosis Related Groups (DRGs) and discharges that have been identified as at high risk for payment errors.
- Recovery Audit Contractors (RACs): The Recovery Audit Contractor (RAC) program was created through the Medicare Modernization Act of 2003 to identify and recover improper Medicare payments paid to healthcare providers and will become permanent for all states by January 1, 2010.
You should be ready to take the CMS quiz now. . . either that or you’re longing for the days when such ABC mashups meant merely another bowl of soup. Nevertheless, this Scrabble-esque snap shot illustrates just how many ways the government uses data to monitor healthcare services from both a quality perspective and a financial perspective. Where data meets documentation. . . that’s where CDI comes in.
CDI programs have place at the RAC prep table
Since the demonstration program launched in 2005, all the talk’s centered around RACs. But why should clinical documentation improvement specialists care about Recovery Audit Contractors? Isn’t that something for the C-suite, the finance folks, and maybe HIM? Well, yes. . . and no. Preparing for RAC audits requires a team approach and while each of the aforementioned groups maintain important roles, CDI programs do to.
RACs came about, as many of you already know, via the 2003 Medicare Improvement and Modernization Act. Medicare contracts with third parties to analyze data in an effort to
- Reduce improper payments
- Collect overpayments
- Identify underpayments
- Implement actions to prevent future improper payments
During the course of the demonstration program CMS collected more than $1 billion in improper payments—approximately 96% of which were overpayments collected from providers. Ond only 4% were underpayments repaid to providers
With such a windfall, it didn’t take CMS long to approve the continuation of the RAC program. Its nationwide rollout should be complete by August so the days spent dreaming of the RACs’ demise are over.
The RAC permanent program currently being rolled out is expected to focus on:
- Services Medicare deems not medically necessary
- Services rendered in inappropriate settings (such as service provided inpatient that should have been outpatient)
- Payments made for incorrectly coded services
All these areas just happen to be ones CDI professionals care about. Furthermore, when the RACs focus on specific clinical documentation problems, facilities with CDI programs in place will have an advantage.
The first thing for CDI program management to do is participate in their facility’s RAC planning team, says Catherine O’Leary, RN, BSN, managing director and founding partner at CSG Health Solutions, LLC. O’Leary will discuss this in her upcoming presentation “The RAC experience: Use your CDI program to proactively address the RAC audits,” slated for Friday, May 15, 8 a.m., in Palace Ballroom III, at Caesars Palace, Las Vegas.
That’s been Mike Alcorn’s experience so far as well. Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center, sits on a RAC team to gather information and monitor RAC hot-button items. The team includes administrators in case management, HIM, quality assurance, and the C-suite.
While CDI programs certainly shouldn’t be looked to as RAC cures, CDI professionals can bring their understanding of many documentation issues into the RAC discussionsto help minimize the effects of the auditors on their hospital.
CDI Talk: When in Doubt, Call a Friend
If you haven’t joined in the discussions taking place on “CDI Talk” you’re missing out on a wealth of information. Some of the recent discussion topics (to name only a few) have been: query forms, BMI, querying for decubitus ulcers, POA, RACs, to name just a few.
You don’t have to be an expert to join in; in fact, questions from new Documentation Specialists are often trigger the most lively discussions! One topic from 3/26 titled “What DRG would you assign” received 25 responses! This topic was a great example of how CDIS see situations differently and the supporting arguments presented were well thought out and detailed. [more]
RAC – Who and What are They and Why Should I Care?
While we’ve been busy working our fingers to the bone performing our chart reviews CMS has been diligently working to come up with ONE MORE THING that will ultimately involve CDI Specialists: the RAC program.
The RAC (Recovery Audit Contractor) program is an outcome of section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). As part of this Act Congress directed the Department of Health and Human Services (DHHS) to conduct a 3-year demonstration program using Recovery Audit Contractors (RACs) to detect and correct improper payments in the Medicare FFS program.
In addition, in section 302 of the Tax Relief and Health Care Act of 2006 (TRHCA), Congress required DHHS to make the RAC program permanent and nationwide by no later than January 1, 2010. [more]
What challenges are you facing? Let’s hear from you
Sometimes it’s difficult to find the time to write a post, but I have a good excuse: I’m busier now than ever since MS-DRGs rolled around. Our CDI team has been developing new query templates, searching out obscure secondary diagnoses and has beenhot on the trail of substantiating conditions present on admission. Sound familiar? [more]