This week several transmittals, including the April quarterly OPPS update, were listed on the transmittals page on the CMS Web site. However, as noted in the transmittals section of the Medicare Weekly Update, we are unable to access the actual transmittal documents. Transmittal numbers appear in the list of transmittals for 2010 and there is some basic information (e.g., subject, effective/implementation dates, etc.), but the links to the transmittal documents are broken. MedicareFind staff have been in contact with CMS multiple times on this issue but there is no resolution at this time. We will report on the affected transmittals when they are made viewable by CMS.
In other happenings this week, the OIG reported on the fraud referral process, or rather, lack of process, during the RAC Demonstration Project. Although RACs received minimal Medicare fraud training, they did identify and report two provider-specific fraud issues, according to the OIG. However, CMS did not have a record of these referrals when asked by the OIG. The OIG recommended CMS follow up on these two referrals, and they have been sent to the OIG for further investigation.
In addition, the OIG recommended that CMS require RACs to receive mandatory training on identification and reporting of fraud. It also recommended that CMS maintain a database to track fraud referrals. CMS concurred with these recommendations and had already started training on the RACs on fraud. For more information, see the report.
I also wanted to share what I have heard from a provider who was the subject of a RAC DRG coding validation audit in North Carolina. They reported to me that they received DRG findings that they did not agree with. They contacted the RAC to discuss the findings during the “Discussion Period” and asked for the credentials of the personnel making the determination, as is allowed under the RAC Statement of Work. They were told the person who reviewed their claim had a CPC coding credential.
A CPC is a Certified Professional Coder, and is a credential granted by the American Academy of Professional Codes. I, myself, am a CPC. It is an outpatient coding credential that would not include expertise in inpatient diagnosis code sequencing for proper DRG assignment. I verified on the AAPC’s web site that even the CPC-H is applicable to “outpatient facility/hospital services”. While familiarity with ICD-9 Volumes 1 & 2 is required to maintain a CPC-H, it does not include use of ICD-9 Volume 3. These are the codes used for inpatient procedures and would be essential for proper coding and DRG assignment for an inpatient case.
The RACs are required by their Statement of Work to employ “certified coders” to complete their reviews. This was added as a requirement in the permanent RAC Program in response to concerns of inappropriate coding denials during the Demonstration Project. While it does appear that using a CPC to review inpatient cases may comply with the letter of the requirement, it certainly would not be in the spirit of the requirement.
I know, even though I have extensive knowledge of the DRG system, I would not feel qualified to do DRG validation because of the complexity of assigning and properly sequencing under the inpatient coding rules, which differ significantly from the outpatient diagnosis coding rules. I often verify my understanding of inpatient coding with our certified inpatient coding experts. It remains to be seen if this is an isolated occurrence, but providers should take a lesson from this facility and use the available discussion period to question the RAC if you do not agree with their determinations. And if you do not receive a satisfactory answer, ensure you exercise your appeal rights.