Archive for RAC
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.
DCS Healthcare added a new semi-automated issue for inpatient rehabilitation facility claims to its CMS-approved list for providers in New Hampshire, Massachusetts, Maine, Vermont, and Rhode Island.
According to the DCS website, the new issue is:
- Late submissions of IRF-PAI date. Inpatient rehabilitation facility-patient assessment instrument (IRF-PAI) data, which is collected on a Medicare Part A fee-for-service inpatient, must be transmitted to the CMS National Assessment Collection Database by the 17th calendar day from the date of the patient’s discharge. Transmission of the IRF-PAI data record 28 or more calendar days after the discharge date, with the discharge date itself starting the counting sequence, will result in the claim incurring a 25 percent (25%) late transmission penalty.
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 a new issue for medical necessity claims to its CMS-approved list for providers in all Region B states.
According to the CGI website, the new issue is:
- Minor musculoskeletal procedures with CC and MCC; MS-DRG 477, 478, 500, 501, 515, 516. The purpose of this complex review is to identify claims that have been reviewed validating medical necessity in short stay, uncomplicated admissions. This review will identify if medical necessity was met per Medicare guidelines.
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.
Connolly Healthcare added eightnew issues across three categories—three for outpatient hospital – unspecified claims, three for medical necessity claims, and two for physician claims— to its CMS-approved list for all providers in Region C states.
According to the Connolly website, the new issues are as follows:
Medical necessity issues
- Diseases and disorders of the eye- MS-DRG’s 121- 125 w/CC, w/MCC , without CC/MCC. RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRG’s 121-125.
- Disease and disorders of the nervous system MS DRG’s 088-093 and 102 w/CC, w/MCC, without CC/MCC CMS Issue Number: C000432012. RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRG’S 088- 092 and 102. Read More→
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