CGI posts approved issues for Region B

Region B, get ready. RACs may begin auditing at any time in several Region B states.

CGI Federal, the RAC for Region B, has posted its first set of issues eligible for RAC audits in Indiana, Michigan, and Minnesota.

The approved issues target outpatient hospital and physician claims and correspond with those approved for many states in RAC regions C and D that were posted over the past few weeks — take a look at the discussions here, here, and here for more.

Check out more RAC-related coverage over at the Revenue Cycle Institute.

Florida RAC Reviews See a New Issue Emerge

Connolly Healthcare, the recovery audit contractor (RAC) for Region C, posted its CMS approved audit issues list for Florida last week.  Connolly had previously posted its issues list for South Carolina; however, when comparing the lists between the two states, there is a slight difference.  Although bronchoscopy services were approved for South Carolina, this issue has not been approved for Florida.

In contrast, a new issue has made its way to the audit list for Florida.  Clinical social worker (CSW) services provided during an inpatient stay at a hospital or a skilled nursing facility (SNF) are not separately payable under Medicare Part B.  When these services are provided by a professional who meets the definition of a CSW and is legally authorized under state law to provide that service, the CSW provider must seek reimbursement directly from the facility. Under their respective prospective payment systems, the facilities have already received reimbursement for these services in their payment. The Medicare Benefit Policy Manual, Chapter 15, Section 170 and MLN Matters SE0439 provide guidance for the proper billing of these services.

This audit issue would fall under the RAC’s automated review process since the Common Working File could identify those patients who were an inpatient in either a hospital or a SNF during the same date of service when social work services were billed to Medicare Part B. Providers who have billed Medicare Part B for CSW services provided to inpatients may want to review their processes.

RAC program: Connolly posts approved issues for Florida

UPDATE: Blood transfusions have since been approved for review in Florida.

Connolly Healthcare, the RAC for region C, has now posted issues for review in Florida.

Similar to South Carolina, RACs may now audit providers in Florida on the following five issues:

• Untimed Codes
• IV Hydration Therapy
• Once in a lifetime procedures
• Pediatric codes exceeding age parameters
• J2505: Injection, Pegfilgrastim, 6 mg

Note that CMS has not approved audits of bronchoscopy services or blood transfusion at this time for Florida providers.

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.

Hat tip to my colleague Andrea Kraynak at the Revenue Cycle Institute. Thanks Andrea!

Inpatient HINNs: Protecting the hospital’s right to recover payment for non-covered services

Last week, I participated in an HCPro audioconference on HINNs. “HINN” stands for hospital-issued notice of non-coverage. It’s the inpatient equivalent of an advanced beneficiary notice (ABN). Under Medicare’s limitation on liability (LOL) provisions, hospitals are required to provide prior notice, in a prescribed form, when certain outpatient or inpatient services ordered by a physician do not meet Medicare’s medical necessity guidelines for the patient’s condition.

In such cases, the ABN is the prescribed form of prior notice for outpatient services, while the HINN is the prescribed from of prior notice for inpatient services. Although the prior notice requirements for LOL have been in place for a number of years, hospitals continue to struggle to provide timely, appropriate notification, particularly in the inpatient setting. [more]

HealthDataInsights launches new RAC Web site, posts issues eligible for audits

HealthDataInsights, Inc. (HDI), launched its new RAC Web site, and posted the first set of issues eligible for RAC review throughout all 20 RAC Region D states and territories on August 12.

The list of issues will likely be familiar to healthcare providers who saw those announced by Connolly Healthcare last week. HDI has posted the following approved issues:

• Neulasta (HCPCS code J2505). RACs will review claims submitted with the total number of milligrams instead of one unit per 6mg. Providers should submit claims for J2505 so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs.
• Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit. Certain service codes are specific to patients of a specific age and should not be applied or billed for patients who exceed the age limit defined by the CPT code.
• Once in a Lifetime. Certain procedures are only performed once in a person’s lifetime. RACs will seek to identify claims paid for those procedures for more than one service date.
• Excessive Units—Untimed Codes. When reporting service units for untimed codes (excluding modifiers -KX and -59) where the procedure is not defined by a specific time frame, the provider should enter a “1” in the units bill column per date of service.
• Excessive Units—Blood Transfusions. Providers should bill blood transfusions with a maximum of one unit per patient per date of service.
• Excessive Units—Bronchoscopy. Providers should bill bronchoscopy services with a maximum number of one unit per patient per date of service.
• Excessive Units—IV Hydration. Providers should bill IV hydration with a maximum number of one unit per patient per date of service.

“These issues are perfect for automated reviews,” says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. “These issues are definitely clear cut. RACs wouldn’t need to request medical records for these.”

But that doesn’t mean the issues the RACs have chosen to begin with aren’t surprising. Mackaman says many providers expected RACs might audit for incorrect Neulasta billing and speech therapy untimed codes. But other choices, such as the newborn codes billed for patients who have exceeded code age limits and “once in a lifetime” procedures, are unanticipated.

“It’s not exactly what we may have expected,” Mackaman says. “But it must be that they found these to be important through their data mining.”

HDI’s list of approved issues also includes the date CMS approved the issue, as well as relevant claim types for each issue, and where providers can find additional information on each topic.

With two RACs now focusing on the same issues, it seems prudent for providers everywhere to review these areas and try to correct any problems they uncover. Mackaman suggests meeting with various departments involved in each of the specific issues. Talk to rehab departments about untimed codes, talk to the pharmacy about Neulasta, and talk to the HIM department about what could be causing the coding problems related to newborn pediatrics, she says. And review documentation for IV hydration as well.

The list is out there, so be proactive, urges Mackaman. “Don’t wait until you receive a RAC letter to begin to review your processes.”

Hat tip to my colleague Andrea Kraynak at the Revenue Cycle Institute. Thanks Andrea!

CMS announces a coverage determination on the “screening virtual colonoscopy”

On August 7, CMS issued transmittal R105NCD to implement its decision to maintain non-coverage of computed tomography colonography (CTC) for colorectal cancer screening, also known as a “virtual colonoscopy.” In 2008, the medical community had recommended that CMS consider coverage of this exam for screening purposes in specific individuals. After performing its own review, CMS has determined that the current medical evidence is inadequate and that no national coverage determination (NCD) is appropriate at this time.

Currently, Medicare beneficiaries can receive one of the following colorectal cancer screening tests:

• Fecal occult blood test (guaiac-based or immunoassay-based) once every 12 months;
• Flexible sigmoidoscopy once every 4 years depending on risk factors;
• Screening colonoscopy once every 10 years for patients without a known risk;
• Screening colonoscopy once every 2 years for patients at high risk for colorectal cancer;
• Barium enema every 4 years as a substitute for a flexible sigmoidoscopy;
• Barium enema every 2 years as a substitute for a screening colonoscopy for high risk patients.

Since CMS has determined that screening CTCs are non-covered for dates of service on and after May 12, 2009, a signed ABN is not required to be able to bill the patient for the service. However, under the revised ABN instructions, it can be used to inform the patient in advance of their financial responsibility.

More information on covered colorectal cancer screening services can be found in the Medicare Claims Processing Manual, Chapter 18, and the Medicare Benefit Policy Manual, Chapter 1.

MedicareFind tip: Bring relevant results NEARer

Knowing that your keywords are close together in a document is important — the closer they are, the more likely it is that the document will have your answer. But with some source authorities weighing in at multiple hundreds of pages — like CMS manuals and Federal Register rulemaking — how can you be sure you’re looking only at documents where your search terms are in the same neighborhood? After all, it won’t do you any good to see “infusion” on p. 1 and “hours” on p. 200 if you’re looking for them both in the same place.

MedicareFind’s NEAR feature can help.

Take a look at this regular search for infusion hours — it brings up about 1,000 results. Using the document type, source, and year/month filters on the left can help zero in from there.

Using the NEAR feature will narrow our results from the start; check out this FIND for infusion NEAR hours. It returns about 325 results. Adding “NEAR” to the query means that MedicareFind will only return documents where “infusion” and “hours” appear close together — so you can avoid scrolling through large documents where the two terms are pages apart. Starting off with fewer documents that are more relevant to your topic also means that any subsequent filtering you do — narrowing by document type, source, or year/month — will be even more powerful.

NEAR also strikes a nice balance between a plain search and a very restricted search with the terms enclosed in quotation marks, in which case MedicareFind looks just for that phrase as a whole. Compare:

• Infusion hours, with about 1,000 results (MedicareFind looks for “infusion” and “hours”)
• Infusion NEAR hours, with about 325 results (MedicareFind looks for “infusion” close to “hours”)
• “Infusion hours”, with about 10 results (MedicareFind looks for the phrase “infusion hours”)

Each of these queries has a place — keep it broad to make sure you don’t miss anything, make it narrow to look for targeted information. Adding NEAR to your research toolbox will give both of these benefits, in moderation. (Note: NEAR must be in all caps, otherwise MedicareFind will assume that the word “near” is a keyword.)

Purchase MedicareFind to start FINDing! You can also sign up for a free trial.

Inpatient Prospective Payment System (IPPS) Final Rule Announced

On July 31, 2009, CMS issued the IPPS final rule announcing the changes that will affect the payment rates and related policies for acute care hospitals and long-term care hospitals that are paid under the prospective payment system. The changes are effective for discharges beginning on October 1, 2009 which is the start of the government’s fiscal year for 2010 (FY2010).

In the proposed rule, there were concerns that the payment rate update of 2.1% minus the documentation and coding adjustment (DCA) of 1.9% were going to leave the annual increase for hospitals flat in the midst of a declining economy.  The final rule brought some good news in that the payments are actually projected to increase by $1.9 billion for IPPS hospitals.

With the adoption of MS-DRGs in FY2008, the diagnosis and the severity of the patient’s illness were reflected in the payment structure.  Ultimately, physician documentation needed to improve in order for the coder to assign the most specific and appropriate MS-DRG for reimbursement related to the intensity of those services used to treat the patient.   In anticipation that documentation would improve overall, thereby causing increased reimbursements to hospitals, Medicare statutes required CMS to make “adjustments” to the annual inpatient rates to prevent excess spending in the Medicare program.  For FY2010, CMS had proposed the 1.9% DCA to offset that anticipated increased spending.  However, based on public comments and the fact that CMS could not definitely determine that FY2009 spending was either higher or lower than projected based on those documentation and coding improvements, CMS chose not to make any DCA adjustment at all to the FY2010 rates.  This change and several other adjustments have projected that the IPPS payments will increase by $1.9 billion during the upcoming fiscal year.

This is good news for many hospitals that are struggling; however, keep in mind that after the FY2009 documentation and coding improvement information has been analyzed by CMS, adjustments will probably be forthcoming.  Facilities who have effective clinical documentation improvement programs in place should continue their efforts and those who do not have one in place should seriously consider it.  The lack of a DCA adjustment this fiscal year could help some hospitals put some “money in the bank” in preparation for future adjustments.

“Voluntary Refunds” to MACs/FIs

Many providers are taking a proactive approach to the arrival of the Medicare Recovery Audit Contractors (RAC) and performing their own audits. Using the RAC “hot topics,” providers are using those audit outcomes to understand their risks, to change internal processes regarding areas of concern and to return reimbursements for claims that were found to be paid in error.

Once a self audit has been performed and if an improper payment has been identified, what should be the provider’s next steps? CMS Frequently Asked Question (FAQ) #9503 was updated last week to clarify the process of notifying the RAC on self audit outcomes.  If an improper payment related to a specific claim is identified, the provider should report their findings to their Medicare Administrative Contractor (MAC) or their Fiscal Intermediary (FI) if their transition to a MAC has not been completed.

A “voluntary refund” based on the specific claim can be made and the MAC/FI will make the appropriate adjustment. For details regarding the required claim information that is necessary to complete a voluntary refund, contact your local MAC/FI.  According to CMS, the “RAC will be aware of the adjustment, but the refund does not preclude future review.” Providers should create an internal process to identify any claims that have been processed as a voluntary refund.

MedicareFind tip: Zero in on your manual with sub-filters

CMS’ manual system is an important source of information and guidance — that’s why the “Manuals” filter appears on our results page. When you type in key words, click “FIND,” and see your list of results, you have the ability to look at only results from the manual system by clicking on the “Manuals” filter.

But — because we know that still might leave you with a lot of results — you can zero in even further. When you apply the “Manuals” filter, two new options appear in the left sidebar: “Internet-Only Manuals” and “Paper Based Manuals”. Clicking on one of these will reduce the number of results and expose another set of sub-filters — this time, the filters correspond to each individual manual’s name. Clicking on one of these lets you view only those results from that particular manual.

For example, look at my FIND for “observation services” — about 5,000 results. Clicking on “Manuals” narrows me down to 136. Going further, into “Internet-Only Manuals,” yields 59. And applying a filter for the “Claims Processing Manual” gets me down to 10 results. Compare that with the more than 16,000,000 results you’d come up against with a regular Google search.

Purchase MedicareFind today and start FINDing! You can also test drive it by signing up for a free trial.