All Entries Tagged With: "drugs"

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!

More on the OPPS proposed rule

Earlier this week, I discussed the physician supervision provisions of the CY2010 OPPS proposed rule.

Another section of interest to many providers will be the sections on the new cardiac rehab, intensive cardiac rehab and pulmonary rehab benefits.  CMS discusses their implementation of these new benefits added to the Social Security Act by the MIPPA, effective January 1, 2010.  Of particular interest is CMS implementation of the MIPPA provision that states that physician supervision for these programs is assumed when provided in a hospital.

Other significant proposals in the rule include a large proposed increase in the OPPS outlier threshold from $1800 to $2,225, the highest the fixed dollar threshold has been since its introduction.

Additionally, a significant portion of the rule was also devoted to payment methodologies for drugs, however, the end resultant proposal for most drugs remains at ASP + 4%.  This includes ASP based payment for therapeutic radiopharmaceutical when the statutory cost based payment methodology expires in 2009.  CMS did make the submission of ASP data for therapeutic radiopharmaceutical voluntary, and will base rates on CY2008 hospital mean cost data if ASP is not available.

Similarly, brachytherapy sources, which also were under a statutory cost based payment methodology for 2009, will be transitioned to CY2008 hospital mean cost data (the usual method for setting APC rates for other services).  CMS is soliciting comments on several of their proposals and I would encourage pharmacy, radiology and chargemaster coordinators to review these proposals carefully and submit comments if they disagree with any of the proposals.