“We were informed that CIGNA will send the letter to the address that is in their file, which is not the address where the demands from Region B RAC were sending the letters to,” she says. “In addition, we received a template yesterday -- I believe CMS released it -- but no envelope was attached so we don’t know what we’re looking for.”
She continued, “It would be nice for the first two months of the switch that the deadlines either be waived or extended. We had been receiving the demand letters usually 7 to 10 days from the date on the letter, so it will be interesting to see how this evolves.”
Do you have any advice, comments, or questions for this provider? Has something similar happened at your facility? Have you contacted/heard back from your particular recovery auditor or MAC?
These “Share your RAC story” submissions are intended to show other provides out there that these things are happening everywhere. But they are also intended to create conversation and connect like-minded individuals. Have you been experiencing any type of problems with recovery auditors lately at your facility? Would you like to offer advice to this reader by sharing your experience? If you do, or if you have ideas, questions, or concerns of your own, then submit them to jcarroll@hcpro.com.
In its most recent (January 20) Medicare Quarterly Provider Compliance Newsletter, CMS once again provides official guidance on correcting problematic billing errors that it identified during the last quarter.
These releases are designed to help providers, suppliers, and billing staff understand claims submission problems while also providing guidance on how to avoid these errors as well as other improper billing activities in the future.
CMS identified the following recovery audit findings in the newsletter (affected provider types in parentheses):
- Ambulance services separately payable during an inpatient hospital stay (Inpatient hospitals, ambulance providers)
- Billing for Arformoterol (Brovana ®) (J7605) and Formoteral fumarate (Perforomist ®) (Q4099) (Durable medical equipment suppliers)
- Diseases and disorders of the circulatory system (Inpatient hospitals)
- Lower limb suction valve prosthesis (Durable medical equipment suppliers)
- Minor surgery and other treatment billed as inpatient stay (Inpatient hospital)
- Respiratory system DRG 076, MS-DRGs 166,167, 177, 178, and 179 (Inpatient hospitals)
- Chronic obstructive pulmonary disease (COPD) MS-DRGs 190, 191, and 192 (Medical necessity review and MS-DRG validation)—Inappropriate and insufficient documentation (Inpatient setting)
- Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD) accessories—Improperly billed quantities (DMEPOS suppliers)
As has been the case thus far, the bulk of the issues affect inpatient hospitals.
To view the most recent quarterly provider compliance newsletter, click here:
http://www.cms.gov/MLNProducts/Downloads/MedQtrlyComp_Newsletter_ICN907703.pdf
DCS Healthcare added 13 new issues for medical necessity claims to its CMS-approved list for providers in Connecticut, Delaware, the District of Columbia, Maine, Massachusetts, New Jersey, New York, New Hampshire, Pennsylvania, Vermont, and Rhode Island.
According to the DCS website, the new issues are:
- DRGs associated with all MCDs. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
- MS-DRG 183 major chest trauma with MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
- MS-DRG 146 ear, nose, mouth and throat malignancy with MCC. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. Read More→
Connolly Healthcare added two new issues across two categories—one for outpatient hospital – unspecified claims and one for physician claims—to its CMS-approved list for providers in Region C states. (See link for individual state applicability.)
According to the Connolly website, the new issues are as follows:
- Excessive dug units billed – Outpatient (At this time, medical necessity will be excluded from this review) CMS issue number: C001552011. Drugs and biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate, discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Drug waste should be coded according to the requirements of the local contractor. Claims billed with excessive units will be reviewed to determine the correct number of billable/payable units.
- Multi-dose vial waste: Trastuzumab (Herceptin), J9355 CMS Issue Number: C000972011. Per its package label, Trastuzumab/Herceptin (J9355: INJECTION, TRASTUZUMAB, 10 MG) is supplied from the manufacturer in a 440mg multi-dose vial. Providers should only be billing units of J9355 associated with the amount of the drug administered to the patient. Drug waste is not paid and should not be billed for drugs supplied in multi-dose vials.
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.
CGI added two new issues for DRG validation claims to its CMS-approved list for providers in all Region B states.
According to the CGI website, the new issues are:
- Other diseases of the respiratory system. The purpose of MS-DRG validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate MS-DRGs with a diagnosis of another disease of the respiratory system that affects the MS-DRG assignment.
- Diseases and disorders of the blood. The purpose of MS-DRG validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate MS-DRGs with a disease or disorder of the blood diagnosis that affects the MS-DRG assignment.
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 12 new issues for medical necessity claims to its CMS-approved list for providers in Connecticut, Delaware, the District of Columbia, Maine, Massachusetts, New Jersey, New York, New Hampshire, Pennsylvania, Vermont, and Rhode Island.
According to the DCS website, the new issues are:
- MDC 11: Diseases and disorders of the kidney and urinary tract. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of: MS-DRG 652 kidney transplant, MS-DRG 653 major bladder procedures with MCC, MS-DRG 654 major bladder procedures with CC, MS-DRG 656 kidney and ureter procedures for neoplasm with MCC, MS-DRG 662 minor bladder procedures with MCC, MS-DRG 665 prostatectomy with MCC, MS-DRG 686 kidney and urinary tract neoplasms with MCC, MS-DRG 688 kidney and urinary tract neoplasms without CC/MCC
- MDC 10: Endocrine, nutritional and metabolic diseases and disorders. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. This review will be of: MS-DRG 618 amputation of lower limb for endocrine, nutritional, and metabolic disorders without CC/MCC, MS-DRG 619 O.R. procedures for obesity with MCC, MS-DRG 622 skin grafts and wound debridement for endocrine, nutritional and metabolic disorder with MCC, MS-DRG 623 skin grafts and wound debridement for endocrine, nutritional and metabolic disorder with CC, MS-DRG 624 skin grafts and wound debridement for endocrine, nutritional and metabolic disorder without CC/MCC, MS-DRG 629 other endocrine, nutritional and metabolic O.R. procedures with CC, MS-DRG 630 other endocrine, nutritional and metabolic O.R. procedures without CC/MCC, MS-DRG 642 inborn and other disorders of metabolism. Read More→
Each month the Revenue Cycle Institute publishes a free sample tool or form for readers. This month’s tool— a sample risk control assessment questionnaire—is useful for determining whether your facility has controls in place to address risk areas contained in the OIG work plan that may apply to your department.
Editor’s note: Access the free tool by clicking here. This sample policy was submitted by Stephen A. Miller, JD, Chief Compliance and Privacy Officer for Capital Health System, Inc., in Trenton, NJ.
A RAC coordinator at a hospital in Region C (who wished to remain anonymous) shared one of her latest recovery auditor stories with the Revenue Cycle Institute. She explained that her facility has been “chasing clues” on confusing RAC demand letters by having to search their RAC tracking tool for every line item on an automated demand letter, which only adds to the existing burdens of RAC coordinators.
“Our letters contain the patient control number, but if not for that, I’d be tempted to report them to Homeland Security or Amnesty International or PETA, or any other agency that ferrets out the bad guys!,” she said, showing her frustration.
She expressed her dissatisfaction when talking about the murky path that RAC coordinators have to follow, alluding to the demonstration project and how its lessons learned should have been factored into the permanent project.
“It’s bad enough to have the financial worries, but whether timelines are being kept (on all sides) or trying to figure out if two line items on a larger letter are either automated or complex demands are more than too much,” she says.
Lastly, she questioned whether or not this process will improve when the MACs begin to send out the demand letters instead of the RACs. In the case of her MAC (Pinnacle), she isn’t looking forward to when the “whole party gets to morph yet again this summer when Highmark takes over. Yikes!”
Has something similar happened at your facility? Have you contacted/heard back from your particular recovery auditor? Do you have any advice, comments, or questions for this provider?
These “Share your RAC story” submissions are intended to show other provides out there that these things are happening everywhere. But they are also intended to create conversation and connect likeminded individuals. Have you been experiencing any type of problems with recovery auditors lately at your facility? Would you like to offer advice to this reader by sharing your experience? If you do, or if you have ideas, questions, or concerns of your own, then submit them to jcarroll@hcpro.com.
Get blog updates in your e-mail
Subscribe to our free RAC Report e-zine