Training Programs
Audits & Assessments
Regulatory Monitoring
- The hospital bill for laboratory services only after they are performed
- The hospital bill only for medically necessary services
- The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
- The current procedural terminology or Healthcare Common Procedural Coding System code used by the billing staff accurately describes the service ordered
- The coding staff submit only diagnostic information obtained from qualified personnel and contact the appropriate personnel to obtain diagnostic information in the event that the individual who ordered the test has failed to provide such information
- The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
- Routine audits be conducted to assess your billing compliance with the regulations
Budgets are tight, but it seems that many healthcare providers are aware that setting aside resources to prepare for RAC audits is non-negotiable.
HCPro’s Revenue Cycle Institute examined this concept as a part of its recent nationwide survey of RAC readiness. The study, which was released recently, garnered more than 700 participants from all four RAC jurisdictions. The respondents hailed from various size healthcare providers: 25% came from hospitals with fewer than 100 beds, another 25% came from hospitals with more than 400 beds, with the remaining 50% falling in between. Approximately 14% of respondents had taken part in the RAC demonstration project.
“Respondents seem to have their RAC preparations well under way, although it’s not surprising that they are struggling with resources to devote to preparation,” according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, and author of the “RAC Preparedness Benchmarking Report,” which details the full results of the survey. Read More→
HealthDataInsights has been approved by CMS to audit for inappropriate billing related to the use of modifiers -TC and -26 on Part B claims in all RAC Region D states.
The new issue is as follows:
- Global vs TC/PC. An overpayment exists when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or professional (modifier 26) components for the same service.
To see an updated list of issues approved in your area, visit the Tools section of the Revenue Cycle Institute Web site, and download our chart of approved RAC issues.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
CMS recently published the Part A deductible and coinsurance and Part B deductible amounts for CY 2010. For most covered inpatient stays, as well as covered outpatient services, Medicare does not pay the entire Medicare allowable for those stays or outpatient services. Beneficiaries generally are responsible for a portion of the Medicare allowable in the form of deductibles and/or coinsurance.
Under Part A, Medicare beneficiaries are entitled to 90 regular benefit days per benefit period. Regular benefit days renew whenever a new benefit period begins. That is, a patient once again has 90 covered inpatient days every time a new benefit period begins. Medicare beneficiaries are also entitled to 60 lifetime reserve days, which may be used after regular benefit days for that benefit period have been exhausted. Lifetime reserve days do not renew. Once used, they are gone forever.
Click over to the MedicareMentor Blog to read more.
The next Hospital & Hospital Quality Open Door Forum is scheduled for 2 p.m. Eastern, Thursday, November 19. To access the call, 800/837-1935 and reference conference ID: 34708559.
A transcript and audio recording of the conference call will be available to MedicareFind subscribers approximately one week after the Open Door Forum is held.
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Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
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Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
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Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
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Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.
HealthDataInsights (HDI) added another new issue approved for RAC audits in all region D states to its Web site.
The new issue is as follows:
- DMEPOS while patient is in a covered Part A inpatient hospital stay.
The Web site provides the following explanation of the new issue: Read More→
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