Aug

20

Self-examination can help ensure compliance with new CMS-approved audit issues

By Andrea Kraynak, CPC-A

By William L. Malm, ND, RN

Connolly and HealthDataInsights (HDI) have released their first set of “approved issues” and facilities now know what they are likely to be confronted with in RAC reviews. But even with the identified issues, facilities still struggle with how to prepare and examine themselves effectively. Fortunately—or perhaps unfortunately—the first set of approved issues will be of an “automated” review nature, most of which involve a unit of service that is greater than one (>1) on the claim.

The following approved issues are unit-based edits for which any facility can review internally: 

• Neulasta: The RAC auditors found that the units of service were inaccurate secondary to a description change. “Neulasta (HCPCS code J2505) Claims submitted with the total number of milligrams instead 1 unit per 6mg. Claims for J2505 should be submitted so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs.”  Facilities can easily audit this issue internally. For example, the chargemaster should be reviewed to ensure that the billing description and units are correctly submitted as “Neulasta per 6mg” with a unit of one. Then the chargemaster staff should review the “multiplier” that converts the dispensing dosage to the billing dosage. Secondarily, utilize your chargemaster (CDM) to identify the volume of units, and then pull actual claims with that chargemaster unique identifier and audit them against the ordered and dispensed units documented in the medical record. The key here is to audit yourself and correct any ongoing patterns of erroneous behavior.
• Blood transfusions: “Blood Transfusions should be billed with a maximum of (1) unit per patient per date of service.”  Once again, this issue is easily identified internally. In this case, a “hard stop edit” should be placed in the billing system to ensure that no claim is submitted with a unit of service in excess of one (>1) on any Medicare claim. Additionally, a retrospective sampling review of claims from 10/01/07 would be beneficial in to identify whether claims were being submitted with units in excess of one. The same methodology should be employed for Bronchoscopy, which also has a maximum of one unit per day.

Another method for identifying potential pharmacy issues such as the Neulasta concern is to compare the “spend” file versus the dispensed units. You should take the total units available for dispensing from your “spend” file and compare it against your total dispensed units of the medication. If the units dispensed exceed the units purchased, this could indicate a billing concern that would be caught in any post-payment audit by any payer.

Other issues that were identified as “approved” can be investigated using your own internal data mining techniques in the same successful manner. It is important to note that the RAC auditors are performing reviews using data mining techniques on your claims, therefore your facility should be able to perform the same steps and resolve any issues successfully beforehand. 

• Neulasta
• Newborn pediatric CPT codes billed for patients exceeding age limit
• Once in a lifetime procedures
• Excessive units—Untimed codes
• Excessive units—Blood transfusions
• Excessive units—Bronchoscopy
• Excessive units—IV hydration

Facilities should start now to understand the “approved issues”, review their chargemaster and begin their own data mining process. The goal is to prevent future errors with the approved issues, and also to identify any issues that may have occurred in the past. In essence, use your current CDM and claims to perform your own root cause analysis. The results will most likely limit your exposure while improving your facility’s operational efficiency.

Editor’s note: William L. Malm, ND, RN, is a healthcare consultant for Craneware. He has more than 20 years of experience in a combination of clinical and financial healthcare, including as a compliance officer, revenue cycle specialist, and chargemaster specialist.

Craneware, Inc. partners with healthcare organizations to improve returns, increase productivity and manage risk, driving sustainable financial and operational performance improvements. For more information, visit Craneware.com.