All Entries Tagged With: "RAC"
Providers report first RAC denials in Florida, South Carolina
Over at the Revenue Cycle Institute, my colleague Andrea Kraynak has a great post on the first RAC denials that we’re seeing so far. There’s some really solid, in-depth information there regarding the experiences of two providers with RAC denials and even a discussion of particular CPT codes affected. Great information for all of us looking to stay on top of this evolving issue.
CMS clarifies RACs’ “exception authority”
On September 11, CMS published Transmittal 302 that updated the Program Integrity Manual on Local Coverage Determination (LCD) exceptions. When specific authorized contractors conduct a complex medical review, they have the authority (in rare and unusual circumstances) to apply an exception to the “reasonable and necessary” requirements described in an LCD to approve or deny a claim. However, they cannot make exceptions to National Coverage Determinations (NCDs). In addition, and unless otherwise directed by CMS, RACs can only use the exceptions process to not deny a claim. This is a good time to review the difference between a national and a local coverage determination policy.
NCDs are coverage policies created by CMS for an item or service to be applied on a national basis for all Medicare beneficiaries. NCDs help ensure that access to advances in technologies that may improve healthcare are available to Medicare beneficiaries when those items and services are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”. However, NCDs may also be used to bar payment for specific items or services that are not “reasonable and necessary”.
LCDs are determinations made by a fiscal intermediary, carrier, or Medicare Administrative Contractor (MAC) in regards to whether or not a particular item or service is covered on an intermediary-, carrier-, or MAC-wide basis. LCDs specify the circumstances under which a service is generally considered to be “reasonable and necessary” to assist providers in submitting correct claims for payment. Medicare contractors develop LCDs when there is no NCD or when there is a need to further define an NCD. The contractors must make sure that all LCDs are consistent with all statutes, rulings, regulations, and national coverage, payment, and coding policies. In addition, codes describing what is covered and what is not covered can be part of the LCD; however, coding guidelines are not elements of LCDs.
It will be important for providers to understand where to locate and how to use an NCD and/or LCD during the RAC review and appeal processes. More information on draft, current and retired NCDs can be found in the MedicareFind database or on the CMS web site. CMS requires all draft, final (active), and retired LCD information to be posted to each contractor’s website.
More on observation services: The Medicare Compliance Forum
Frequent MedicareMentor readers will be aware of the series of posts my colleague Kimberly Hoy has written on observation services — read the ongoing discussions here, here, and here. You can hear Kimberly say a bit more about the cluster of issues surrounding observation at the upcoming Medicare Compliance Forum.
The “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors”, is an upcoming seminar with a whole track of sessions that will help you resolve observation-related questions and problems. Kimberly joins other experts such as ACS’ Deborah Hale, CCS, and Executive Health Resources’ Joe Zebrowitz, MD.
I’ve found the back-and-forth on observation here on the MedicareMentor Blog to be very substantive and illuminating (many thanks to those who’ve commented!), and you can expect the same rigorous, source-based analysis in the forum sessions.
Check out the event brochure, additional tracks, and more on the Medicare Compliance Forum page.
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!
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!
“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.
Mass adjustment to post-acute transfer cases assigned to MS-DRG 956
On May 8, 2009, CMS released transmittal R492OTN. This transmittal instructed Part A contractors (Fiscal Intermediaries and Medicare Administrative Contractors [FIs/MACs]) to download the revised FY 2009 IPPS Pricer and to mass adjust claims that meet the following criteria:
- Have a discharge date on or after October 1, 2008;
- Were assigned to MS-DRG 956; and
- Were assigned a transfer Price Return Code of ‘10’.
