Connolly Healthcare added 12 new issues across five categories—four for DRG validation claims, three for medical necessity claims, three for physician claims, one for outpatient hospital claims, and one for home health agency claims— to its CMS-approved list for all providers in Region C states.
According to the Connolly website, the new issues are as follows:
DRG validation claims
- Skin debridement w/o CC/MCC MS-DRG 572, CMS issue number: C000562012. DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewers will validate for MS-DRG 572, previously DRG 440, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
- Skin debridement w CC MS-DRG 571, CMS issue number: C000552012. DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital in its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewers will validate for MS-DRG 571, previously DRG 440, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Read More→
During the past few months, there have been a number of Office of Inspector General (OIG) reports released that seem to question some of CMS’ audit programs and perhaps find them lacking. It remains uncertain why the release of these audit reports have come within such a short window of time, but the fact that they are occurring should be an indication that CMS’ methods and processes are far from perfect.
The following is a look at some of the recent OIG critiques of CMS.
Audit MIC performance
One such report is an early assessment of the efforts of Audit Medicaid Integrity contractors (Audit MICs) to identify overpayments in Medicaid. The report, released on March 20, indicates that only 11% of the study-assigned audits were completed with findings of $6.9 million in overpayments, $6.2 million of which resulted from seven completed collaborative audits involving Audit MICs, Review MICs, states, and CMS. This leaves 81% of audits that the MICs were unable to or unlikely to identify any underpayments or overpayments. The OIG deduced that problems with the data used and analyses conducted by Review MICs and CMS to identify audit targets hindered the performance of the Audit MICs. Read More→
Each month the Revenue Cycle Institute publishes a free sample tool or form for readers. This month’s tool— a level of care pocket card—is a helpful tool that provides important “points to remember” when it comes to outpatient surgery as well as information on the appropriate use of observation services.
Editor’s note: Access the free tool by clicking here. This form was submitted by Deborah Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK.
CGI added two new issues for outpatient claims to its CMS-approved list for providers in all Region B states.
According to the CGI website, the new issues are
- Outpatient Zoledronic Acid (Reclast®)) 1 mg – Units billed versus units reported. The purpose of the automated review is to establish edit parameters and workflow guidelines to conduct an automated review to identify incorrect number of units billed for covered/allowed services of Zoledronic Acid (Reclast®) 1 mg. An overpayment exists when a provider(s) bills for greater than 5 units of service for HCPCS code J3488 for the same date of service.
- Hyperbaric oxygen therapy correct coding. The purpose of this semi-automated review is to establish edit parameters and workflow guidelines to identify claims that have been incorrectly reported for Hyperbaric Oxygen therapy. Claims for HBO of the treatment of diabetic wounds of the lower extremity require documentation of dual diagnoses. An ICD-9-CM code from either the 250.70-250.73 range or the 250.80-250.83 range (representing a diabetes-related problem) plus one of the following ICD-9-CM codes: 707.10, 707.11, 707.12, 707.13, 707.14, 707.15, or 707.19 (representing a lower extremity wound) must be reported.
To stay on top of the latest RAC-approved issues in your state, visit the “Tools” Section of the Revenue Cycle Institute Web site and download the updated chart at the top of the page.
DCS Healthcare added two issues across two categories—one for physician/non-physician practitioner claims and one for critical access hospital claims—to its CMS-approved list for providers in Region A. (See link for individual state applicability.)
According to the DCS website, the new issue is:
- MRI scans. Potential incorrect billing of MRI scans not supported by medical necessity (NGS LCD L28518 [A48016])
To stay on top of the latest RAC-approved issues in your state, visit the “Tools” Section of the Revenue Cycle Institute website and download the updated chart at the top of the page.
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