Archives

Archives (248)

j-gillAs is the case with many RAC provider and hospital issues, the first stop on the national level for providing contractors with guidance on billing and coding is the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).

Not surprisingly, an August 2010 DEI report (05-09-0030) written by Inspector General Daniel Levinson was virtually an "open door" to scrutinize coding and documentation practices for pain management providers further.

During a period of four years, the OIG reported a 150 percent increase ($84 million) for payments relating to transforminal epidural injections. The summary essentially revealed three main areas of deficiency: a) improper use of "add-on" codes; b) lack of documentation to support the injection and/or imaging; and c) lack of enforcement by carriers to enforce LCD requirements.

By looking through the published issues for all RAC items carefully, contractors are finding lucrative ways to review at automated and predicted complex levels of audit.

Sticky Issue: Denervation

One of the newest issues, most likely stemming from this OIG finding, focuses on documenting the method of guidance when performing facet joint denervation.

As cited by HDI, LCD L28288 requires placement of a needle in the facet joint under fluoroscopic or CT guidance when performing facet denervation. Furthermore, this is defined clearly in the CPT code description. Although the RACs can identify utilization data for providers, they will have to bring this down to a partial or complex level to determine that the procedure has been documented properly.

In other recent CMS articles, the agency also notes that providers continue to bill for imaging in addition to using the CPT codes that include the service as an integral part of the procedure.

As these claims are adjudicated and sometimes paid, the liability of the provider, between correcting and re-paying the carrier, is extreme. Modifiers also can complicate the situation if the ASC or hospital are billing for the technical component of a bundled service. The OIG report revealed that there is not enough transparency within the process of making MAC edits to catch these billing errors consistently.

Audit Preparation

Given the depth of the OIG investigation and the issues posted by RACs, how should providers prepare for these types of audits?

  • The first step is to focus on key areas of education, such as knowing your LCD and NCDs as they apply to your region. LCDs are very specific in terms of regulatory direction, documentation requirements and medical necessity for certain procedures.
  • Internal and external audits are another key compliance area to monitor, and doing so will allow you to provide feedback to physicians and relevant staff.
  • Whether your coding staff is using CAC or standalone tools, make sure they are current for the year and that these tools are updated each calendar year, because codes continually change.
  • As ICD-10 emerges, translate the LCD-required ICD-9 codes into I-10 using a GEMs mapping tool to show providers the finite detail soon to be required for claims processing.
  • Finally, hotlink to local and national CMS resources to stay connected with court cases, fraud alerts and updated RACmonitor postings.

About the Author

Jana Gill, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services. 

Contact the Author

Jana.Gill@WoltersKluwer.com

To comment on this article please go to editor@racmonitor.com

OIG Work Plan Challenges Continue for Physicians

k-long

alert-powered-by-decision-health

 

 

 

 

 

 

 

 

In a relatively quiet week for the RACs, three durable medical equipment issues and one outpatient hospital issue were posted.

The DME issues, posted by the RAC in regions B and C, tackle pharmacy dispensing and osteogenesis stimulators and overuse of PAP/RAD accessories.

For more details, see below.

Outpatient hospital

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Leuprolide 3.75mg incorrect code reported

 

9/26/11

RAC Region B

The purpose of the complex review is to identify the incorrect use of HCPCS code and corresponding number of units billed for services of Leuprolide (depot suspension) 3.75mg. An overpayment exists when a provider bills for greater than 3 units of service for HCPCS code J1950, as defined by applicable Local Coverage Determination documents.

CMS Pub. 100-02 chapter 15; National Government Services LCD L26369; Wisconsin Physicians Services Insurance Corporation LCD L30479

Pharmacy supply dispensing fee

10/5/11

RAC Region B

Medicare pays pharmacy supply/dispensing fees for immunosuppressive, oral anti-cancer, chemotherapeutic, and oral anti-emetic drugs as well as drugs used as part of an anti-cancer chemotherapeutic regimen when they are submitted on the same claim as the drug being billed. A claim submitted with a pharmacy supply/dispensing fee in the absence of any of the previously mentioned drugs represents an overpayment and will be denied as not medically reasonable and necessary.

Social Security Act Section 1842(o)(2); Title 42 CFR Part 447; CMS Pub. 100-04 chapter 17; CMS Transmittal 754; NGS LCDs L27005, L27036, L27127, L27226; NGS policy articles A47058, A47233, A47234, A47235; CMS Medlearn Matters Article #MM3990

Osteogenesis stimulators

9/29/11

DME suppliers who bill CIGNA Government Services

An overpayment exists when a provider bills for an osteogenesis stimulator with an ICD-9 code that is not included in the list of covered ICD-9 codes within the applicable Local Coverage Determination documents.

CIGNA LCD L5012

Overuse of PAP/RAD accessories 9/29/11 DME suppliers who bill CIGNA Government Services

A supplier must not dispense more than a certain quantity of PAP/RAD accessories at a time. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary.

CGS LCDs L11518, L5023

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

a-wachler

j-Colagiovanni

With much of the attention focused on Recovery Audit Contractors (RACs) during recent years, providers may be unfamiliar with the other audit contractors utilized by the Centers for Medicare & Medicaid Services (CMS). CMS recently released a MLN Matters article in an effort to increase provider awareness of the current contracting environment and the various entities that may request medical records or other documentation. It is important for providers to recognize these various CMS contractors and the different roles they play. Different contractors serve different functions, including claims processing, program integrity, specialty medical review, appeals and quality improvement.

Claims processing contractors are entities contracted by CMS to process provider enrollment applications and claims submitted by providers and suppliers, and to make payments in compliance with Medicare regulations and policies. Currently, these entities include carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and Medicare Administrative Contractors (MACs). Due to a provision of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, claims processing authority currently is being transitioned to the MACs (much of the carrier, FI, and RHHI workload already has or will be shifted to MAC jurisdictions). The MACs also perform duties such as recovering overpayments on previously processed claims, handling provider enrollment issues, providing education on Medicare billing procedures and resolving issues pertaining to submitted claims. Recently CMS announced that MACs also will be responsible for issuing demand letters in connection with RAC-identified overpayments beginning in January 2012.

Program Integrity contractors are responsible for identifying cases of suspected fraud. Specifically, CMS contracts with Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs), which are in charge of implementing the Medicare Benefit Integrity program. PSCs and ZPICs use a variety of proactive and reactive techniques to identify and address potentially fraudulent billing practices. CMS is currently in the process of transitioning PSCs to ZPICs, which soon will perform all benefit integrity work. Seven ZPICs were created to perform program integrity for Medicare Parts A, B, C and D (prescription drugs), plus DME, home health and hospice, and Medi-Medi.

CMS also has contracted with the Recovery Audit Contractors (RAC) to carry out program integrity efforts. RACs conduct automated, semi-automated and complex reviews in an effort to identify and recover improper payments (i.e. underpayments and overpayments). There are four RAC regions, each with its own contractor: Diversified Collection Services (Region A), CGI (Region B), Connolly Consulting (Region C) and HealthDataInsights (Region D). The Tax Relief and Health Care Act of 2006 authorized the RAC program for Medicare Parts A and B. The Patient Protection and Affordable Care Act of 2010 expanded the program to cover Medicare Parts C and D as well as Medicaid. The Medicaid RAC program was created as a tool to fight Medicaid fraud and abuse, and the program shares some similarities with the Medicare RAC program. CMS released the final rule for the Medicaid RAC program on Sept. 14, 2011.

Medicaid Integrity Contractors (MICs) contract with CMS to perform program integrity work. There are three types of MICs: Review MICs, Audit MICs and Education MICs. Review MICs are responsible for investigating potential provider fraud, waste or abuse. Audit MICs are the Medicaid version of RACs in that they audit claims submitted by providers and identify improper payments. However, unlike the RACs, which are limited to a three-year lookback period, Audit MICs may review claims dating back up to five years. Education MICs are responsible for educating providers regarding payment integrity and quality-of-care matters.

Specialty Medical Review Contractors are tasked with preventing and minimizing improper payments.These contractors include the Medicare Coordination of Benefits Contractor (COBC), whose duties include overseeing all activities that support the collection, management and reporting of other insurance coverage for Medicare. Another specialty contractor is the Medicare Secondary Payer Recovery Contractor (MSPRC), which is responsible for recovering funds for which Medicare should not have been the primary payer. Finally, the National Supplier Clearinghouse (NSC) has been contracted by CMS to handle enrollment activities related to DME suppliers.

CMS also has contracted with entities to conduct first- and second-level provider appeals of claim denials. First-level appeals (redeterminations) are conducted by carriers, FIs, RHHIs and MACs.For second-level appeals (reconsiderations), CMS has contracted with Quality Independent Contractors (QICs), which conduct independent reviews of the initial determination, any redetermination and other issues related to payment of the appealed claim. There are seven QICs in total: two Part A QICs, two Part B QICs, one Part C QIC, one Part D QIC and one DME QIC.


 

Administrative Law Judges (ALJs) oversee the third level of the appeals process. ALJ hearings may be conducted in person, by video teleconference (VTC) or by telephone. During these hearings, parties have an opportunity to present documentary evidence, legal arguments and witness testimony, which may involve internal clinicians and experts. The ALJ will examine the issues, question parties and other witnesses, and review documents material to the issues. An ALJ’s decision is based on the hearing record and is required to be made within 90 days from the date a request for the hearing was received (unless the time period is extended or waived).

If a provider is unsatisfied with an ALJ decision, it may appeal the decision to the Medicare Appeals Council (MAC). A MAC decision typically is issued within 90 days of receipt of a request for appeal. The MAC’s decision binds all parties unless the decision later is modified by a federal district court; if the MAC does not issue a decision, dismissal or remand within the required time frame, a provider may request that the case be accelerated to federal district court.

Quality Improvement Contractors, also known as Quality Improvement Organizations (QIOs), are private organizations (mostly nonprofits) whose staff consists mostly of physicians and other healthcare professionals. Each state, as well as the District of Columbia, Puerto Rico and the Virgin Islands, has its own QIO. The role of the QIO is to provide quality-of-care review services and to implement quality improvement projects. QIOs are tasked with improving quality of care for beneficiaries and ensuring that care is medically necessary, reasonable, provided in the appropriate setting and rendered in accordance with recognized healthcare standards.

While the audit landscape and its numerous acronyms can be intimidating, providers are advised to arm themselves with knowledge about the roles of the various contractor entities. Understanding the focus of each can provide significant insight if and when a provider receives a record request or experiences an audit of claims.

About the Authors

Andrew B. Wachler is the principal of Wachler & Associates, P.C.  He graduated Cum Laude from the University of Michigan in 1974 and was the recipient of the William J. Branstom Award. He graduated Cum Laude from Wayne State University Law School in 1978. Mr. Wachler has been practicing healthcare and business law for over 25 years and has been defending Medicare and other third party payor audits since 1980.  Mr. Wachler counsels healthcare providers and organizations nationwide in a variety of legal matters.  He writes and speaks nationally to professional organizations and other entities on a variety of healthcare legal topics.

Jennifer Colagiovanni is an attorney at Wachler & Associates, P.C.  Ms. Colagiovanni graduated with Distinction from the University of Michigan and Cum Laude from Wayne State University Law School.  Upon graduation, Ms. Colagiovanni was nominated to the Order of the Coif. Ms. Colagiovanni devotes a substantial portion of her practice to defending Medicare and other third party payer audits on behalf of providers and suppliers.  She is a member of the State Bar of Michigan Health Care Law Section.

Contact the Authors

awachler@wachler.com

jcolagiovanni@wachler.com

To comment on this article please go to editor@racmonitor.com

e-lamkinIf you read our last article, “The RAC Tsunami on the Horizon,” you know that The Centers for Medicare & Medicaid Services (CMS) will be pushing the RACs to make up for a projected $307.5 million shortfall from the agency’s financial goal for 2011.

As we study the RACs’ recent focus on automated reviews and the need to escalate recoupment, we predict that healthcare providers will experience an increase in activity when it comes to complex reviews related to medical necessity. According to the American Hospital Association, the difference in recoupment per claim between the average automated recoupment and the average complex recoupment is $4,882 ($399 for the former, $5,281 for the latter).

Couple this with the new CMS Statement of Work (SOW) for RACs, published Sept. 12 – which calls for RecoveryAuditors to review all provider types (page 8-9) – and it adds up to a daunting set of circumstances. We believe this will affect the following types of services:

·Outpatient hospitals

·Physician/non-physician practitioners

·Home health agencies

·Laboratories

·Ambulance services

·Skilled nursing facilities

·Home health agencies

·Suppliers

·Inpatient rehabilitation facilities

·Critical-access hospitals

·Long-term care hospitals

·Ambulatory surgical centers

We also believe these factors will incentivize RAs to elevate medical necessity as a leading RAC target once again.

For all healthcare providers, getting medical necessity right on the front end is crucial to preventing recoupments. Hospitals are particularly vulnerable, but with the right structure, processes and people in place, you can get it right most of the time and have the documentation in place to mount successful appeals.

First, the structure – and by structure we mean the right committees and reporting relationships. A RAC committee should be the mechanism through which the financial and clinical sides of a practice come together, and it also should be a permanent part of the quality reporting system. This ensures accountability and awareness on the part of the governing board.

Secondly, implement an effective process through which staff members review each and every admission for proper bed placement. The process should gauge compliance with meeting medical necessity and ensure adherence to policies and procedures covering the documentation of severity and intensity of illness.

The third item to consider, again, is people. The right culture, people and training are essential to achieving success. Specifically, there are three key positions that play critical roles in billing and RAC compliance: the admission care manger, the physician advisor and the clinical documentation specialist.

We suggest filling an admission care manager position (or positions) as a first line of defense. This person works with the admissions department and physicians to ensure that requested bed statuses meet criteria. Remember, only a physician may request an inpatient stay. All admissions, not just inpatient admissions, must be reviewed within 24 hours to allow time for queries if necessary.

The physician advisor role also is crucial because admission care managers may have questions about admissions or find themselves unable to win the cooperation of admitting physicians. The physician advisor often emerges as a valued peer and consultant regarding care management, plus a liaison to the medical staff. This person also leads utilization review and is a key member of the utilization committee. This is especially helpful with Code 44, in which the inpatient bed status is changed from inpatient to outpatient prior to patient discharge. The PA and care management department also are key to working with attending physicians to change orders – and notifying and explaining changes to patients when there are financial implications.

The final key role, again, is the clinical documentation improvement specialist (CDIS), who most likely will work within the HIM department. This person audits relevant documentation for appropriateness and works with staff and physicians to meet criteria for intensity and severity of care. This staff member is also a key to higher-quality care, as the CDIS interfaces between all clinicians to ensure that everyone is aware of key documentation. For instance, if a physician misses therapy notes indicating a change in status, the CDIS can notify the physician and make a query to clarify any subsequent orders.

One indicator that will be key to monitor after implementing the above guidelines is the number of queries made by HIM coders. There should be a dramatic drop in the number of queries required by coders, resulting in better reimbursements, less undercoding and less manpower for HIM – thus offsetting the cost of salaries for the three key positions named above.


 

About the Author

Elizabeth Lamkin, MHA, is a partner in PACE Healthcare Consulting. Elizabeth has more than 20 years of C-suite level hospital executive management experience.  Most recently, she was the CEO/Market President for Tenet Healthcare's Hilton Head Regional Healthcare. Elizabeth holds an undergraduate degree in Business Administration, Cum Laude and a Master's in Healthcare Administration from the University of South Carolina.

Contact the Author

Elizabeth.Lamkin@pacehcc.com

To comment on this article please go to editor@racmonitor.com

 


Footnotes:

1.Source: CMS, “Medicare Fee-for-Service Recovery Audit Program as of June 2011.” Retrieved Aug. 31, 2011 from http://www.cms.gov/Recovery-Audit-Program/Downloads/NatProg.pdf.

2.Source: Axsom-Brown, V. “RACs Fall Short in Third Quarter by $82.5 Million.” RAC Monitor.Retrieved August 7, 2011, fromwww.racmonitor.com/news/3-feature-aritcles/624-racs-fall-short-in-third-quarter-by-825-million.html.Source: AHA, “Exploring the Impact of the RAC Program on Hospitals Nationwide: Results of AHA RACTrac Survey, 4thQuarter 2010, February 24, 2011.” Retrieved July 26 fromhttp://www.aha.org/aha/content/2011/pdf/Q4-2010-RACTrac-results-chartpk.pdf.

3.Bruce Redler, M.D. Medical Advsior, PACE Healthcare Consulting, LLC.

4.For information on our book, the RAC Toolkit for Hospitals and Health Systems, visit our website atwww.pacehcconsulting.com. A RAC workbook for physician practices will be available in October 2011.

k-long

alert-powered-by-decision-health

 

 

 

 

 

 

 

 

RACs in Region A, B and D posted new issues this past week. But of note, Connolly, the Region C RAC, modified its list of issues to include a date posted and allow for sorting by issue name, issue type, claim type, state affected and date approved.

The new issues are below.

Part A

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review – MDC 6 diseases and disorders of the digestive system; MS-DRGs 347,348, 349, 350, 351, 352, 353, 354, 355, 356, 357, 358, 368, 369, 370, 371, 372, 373, 374, 375, 376, 377, 378, 379, 380, 381, 382, 383, 384, 385, 386, 387, 388, 389, 390, 391, 392, 393, 394, 395

9/27/11

Md.

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.

Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; PEPPER Reports; OIG reports A-01-10-01000, A03-00-00007, OAI-05-88-00730; Change request 3200, transmittal 156; admission of less than 24 hours policy – Maryland

Medical necessity: Acute inpatient admission respiratory conditions (collaborative); MS-DRGs 177-180, 190-198, 202-206

9/27/11

Md.

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.

RAC demonstration evaluation; CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 13; Section 1814(b)(3) of the Social Security Act; Change request 3200, transmittal 156; admissions of less than 24 hours policy – Maryland

Medical necessity review – MDC 5 conditions of the circulatory system (Medical); MS-DRGs 286, 287, 288, 289, 290, 291, 292, 293, 299, 300, 301, 302, 303, 304, 305, 308, 309, 310, 311, 312, 313, 314, 315, 316

9/19/11

Md.

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.

Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; PEPPER Reports; OIG reports A-01-10-01000, A03-00-00007, OAI-05-88-00730; Change request 3200, transmittal 156; MLN Article #MM3200; admission of less than 24 hours policy – Maryland

 

 

 

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity: Acute inpatient admission neurological disorders; MS-DRGs 068,069, 070, 071, 072, 073, 074, 103, 312 (collaborative)

9/27/11

Md.

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.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 13; RAC demonstration evaluation; Section 1814(b)(3) of Social Security Act; Change request 3200, transmittal 156; admissions of less than 24 hours policy – Maryland

Acute inpatient hospitalization – infections, female reproductive system with MCC (DRG 757)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – malignancy, male reproductive system with MCC (DRG 722)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – endocrine disorders with CC (DRG 644)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – menstrual and other female reproductive system disorders without CC/MCC (DRG 761)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


 

Acute inpatient hospitalization – menstrual and other female reproductive system disorders with CC/MCC (DRG 760)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – infections, female reproductive system without CC/MCC (DRG 759)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – malignant breast disorders with MCC (DRG 597)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – skin ulcers without CC/MCC (DRG 594)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – skin ulcers with CC (DRG 593)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – diabetes without CC/MCC (DRG 639)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – trauma to the skin, subcutaneous tissue and breast with MCC (DRG 604)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


Acute inpatient hospitalization – malignant breast disorders with CC (DRG 598)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major cardiovascular procedures with MCC or thoracic aortic aneurysm repair (DRG 237)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major cardiovascular procedures without MCC (DRG 238)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – malignancy of hepatobiliary system or pancreas with MCC (DRG 435)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – viral meningitis with CC/MCC (DRG 075)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – viral meningitis without CC/MCC (DRG 076)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – coronary bypass without cardiac cath without MCC (DRG 236)

9/16/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


DME by physician

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Excessive billing of positive airway pressure (PAP) and respiratory assist device (RAD) accessories

9/19/11

RAC Region B

Medicare allows payment of PAP and RAD accessories when coverage criteria for the devices have been met. However, the National Government Services Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L27230) state that when supplies are dispensed more frequently or in quantities of supplies greater than usual maximum amounts are dispensed, they will be denied as not medically reasonable and necessary.

Social Security Act, Volume 1, Title XVIII; CMS Pub. 100-04 chapter 20; CMS Pub. 100-08 chapter 4; National Government Services (NGS) LCD L27230; NGS Supplier Manual chapter 15; NGS Article A47228; NGS April 27, 2010, and May 10, 2010, webinar question-and-answer summary

Professional

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Verteporfin and ocular photodynamic therapy without fluorescein angiography

9/19/11

RAC Region B

The purpose of this audit is to identify overpayments associated with providers billing for Verteporfin (J3396) and Ocular Photodynamic Therapy (OPT) (67221-67225) in the absence of fluorescein angiography (92235) or indocyanine-green angiography (92240) performed prior to each treatment.

CMS Pub. 100-03 chapter 1; Wisconsin Physicians Services (WPS) Fluroescein Angiogram

Multiple dose allergy vials

9/19/11

RAC Region B

The purpose of this complex review is to ensure accurate reporting of CPT code 95165 (preparation and provision of antigens for allergen immunotherapy).

CMS Pub. 100-04 chapter 12; National Government Services; Palmetto LCD L6955; Wisconsin Physicians Services (WPS) immunotherapy

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

k-long

alert-powered-by-decision-health

 

 

 

 

 

 

 

Part A providers in Recovery Audit Contractor (RAC) Region D have 14 new issues to worry about.

HealthDataInsights, the RAC for the 17 states and three territories in Region D, posted the acute care hospitalization issues and will review the medical necessity of those services.

DCS Healthcare Services, the RAC in Region A, posted one issue for Maryland Part A providers.

Part A

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review – MDC 5 conditions of the circulatory system (medical) MS-DRGs 286, 287, 288, 289, 290, 291, 292, 293, 299, 300, 301, 302, 303, 304, 305, 308, 309, 310, 311, 312, 313, 314, 315, 316

9/19/11

Md.

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.

Social Security Act sections 1886(d), 1814(b)(3); CMS Pub. 100-08, chapter 13; CMS Pub. 100-02, chapter 1; CMS Pub. 100-04, chapter 3; Pepper Reports, OIG Reports A-01-10-01000, A-03-00-00007, OAI-05-88-00730; Change request 3200, transmittal 156; MLN Article #MM3200; Admissions of less than 24 hours policy – Maryland

Acute inpatient hospitalization – cardiac valve and other major cardiothoracic procedures with cardiac cath with CC (DRG 217)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – cardiac valve and other major cardiothoracic procedure with cardiac cath with MCC (DRG 216)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pneumothorax without CC/MCC (DRG 201)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – deep vein thrombophlebitis with CC/MCC (DRG 294)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


 

Acute inpatient hospitalization – skin ulcers with MCC (DRG 592)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – cardiac congenital and valvular disorders without MCC (DRG 307)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – cardiac congenital and valvular disorders with MCC (DRG 306)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pleural effusion with MCC (DRG 186)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major chest trauma without CC/MCC (DRG 185)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – major chest trauma with CC (DRG 184)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pleural effusion with CC (DRG 187)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

 


 

Acute inpatient hospitalization – pneumothorax with CC (DRG 200)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pneumothorax with MCC (DRG 199)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization – pleural effusion with CC/MCC (DRG 188)

9/8/11

RAC Region D

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.

CMS Pub. 100-02, chapters 1 and 6; CMS Pub. 100-08, chapter 6

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

k-long

alert-powered-by-decision-health

 
 

 

Along with the federal program, providers have to watch out for state recovery audit contractors (RACs) starting in 2012.

States that fail to implement their Medicaid RAC programs by Jan. 1 could lose federal financial participation (FFP), according to the final rule posted Sept. 14 as reported by MICmonitor. States will determine what contingency fee to pay their Medicaid RACs, though the federal government will not provide payments for fees that exceed the highest contingency rate of the Medicare RACs.

CMS will require Medicaid RACs to be similar to their federal counterparts in several ways, including the following:

  • Hiring at least one full-time medical director who is a doctor of medicine or doctor of osteopathy;
  • Hiring certified coders, unless the state determines they are not required to review Medicaid claims effectively;
  • Educating providers, “including notification to providers of audit policies and protocols;”
  • Requiring RACs to have several customer-service measures;
  • Limiting review to a three-year look-back period; and
  • Establishing a limit on the number and frequency of records the RAC can request.

States, however, have the flexibility to design their own RAC programs relating to medical necessity reviews, extrapolation of audit findings, external validation of the accuracy of RAC findings and types of claims audited, the final rule states.


New RAC postings

Connolly, the recovery auditor (RAC) for Region C, posted two new issues this week.

Outpatient hospital

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect billing of vaccine administration services

 

RAC Region C

Vaccine administration (90471-90472) are required to be billed with revenue code 0771 for all providers except RHC & FQHC. Providers billed CPT(s) 90471-90472 in revenue codes other than 0771 resulting in billing errors.

CMS Pub. 100-04, chapter 18; TrailBlazer Health Enterprises LCD for immunizations L26762

 

Physician

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect billing of J1642 – Heparin, up to 10 units (Hep-Lock, Hep-Flush) – carrier

 

RAC Region C

Claims identified where J1642 (Heparin, up to 10 units [Hep-Lock], [Hep-Flush]) was billed for patients who receive Heparin for therapeutic infusion. The therapeutic infusion of Heparin should be J1644 (Heparin, up to 1,000 units).

CMS 2010 Table of Drugs, CMS website Alpha-Numeric HCPCS

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

r-wiitala

In July, the Centers for Medicare & Medicaid Services issued a fact sheet to explain everything physicians and suppliers need to know about the definition and the collection process related to overpayments. It also provides resources where they can learn more. Medicare physicians and suppliers who have not yet gone through this process may find the data within the document useful.

Definition First

A Medicare overpayment is exactly what it sounds like it is-a payment received in excess of amounts due and payable under Medicare statute and regulations. Once an overpayment has been determined, the amount becomes a debt owed to the federal government, and federal law requires that CMS recover all identified overpayments.

There are several reasons that overpayments occur, including the following:

  • Duplicate submission of the same service or claim;
  • Payment to the incorrect payee;
  • Payment for excluded or medically unnecessary services; or
  • A pattern of furnishing and billing for excessive or non-covered services.

Collection and Appeals

A mere overpayment of $10 or more launches the recovery process, and a "demand letter" is sent requesting payment. Interest accrues from the date of the letter if the overpayment is not received by the 31st calendar day from the date of the letter. No response prompts a second demand letter to be sent with the expectation that payment will be received with 40 days of the first demand letter.

If payment isn't received, the recoupment process begins, which means that the overpayment will be recovered from current payments due or from future claims submitted. If the debt continues to be unpaid and no appeal has been filed, the provider or supplier will receive what's called an Intent to Refer letter within 120 days. This letter means that the feds are done fooling around and that the overpayment may be eligible for referral to the Department of Treasury for offset or collection.

Luckily, the next step gives a break to physicians or suppliers who simply cannot pay the entire amount of the overpayment in full. It's called and extended repayment plan.

In the last part of the fact sheet, CMS provides the details of rebuttals and appeals, which include redeterminations and requests for reconsideration, and, in general, what to do when you don't agree with the overpayment declaration.

All in all, the fact sheet makes it easy to understand the steps that providers and suppliers who receive an "overpayment" verdict from their RACs reviews can take if they disagree with the pronouncement.

For the fact sheet, go to https://www.cms.gov/MLNProducts/downloads/OverpaymentBrochure508-09.pdf

About the Author

Randy Wiitala, BS, MT (ASCP) is a senior healthcare consultant with Medical Learning, Inc. (MedLearn), St. Paul, MN. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that will equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.

Contact the Author

rwiitala@medlearn.com

To comment on this article please go to editor@racmonitor.com

HEAT Charges 91 in $295 Million Fraud Schemes

k-longDoctors, nurses and health care company owners were among the 91 people in eight cities charged in the largest single-takedown amount in the history of the Health Care Fraud Enforcement and Prevention Action Team (HEAT).

About 400 law enforcement officers from agencies including the FBI and HHS Office of Inspector General participated in the 91 arrests, which occurred over two weeks, HHS stated.

The schemes, which totaled $295 million in fraudulent billing, included home health, physical and occupational therapy, mental health services, psychotherapy and durable medical equipment, HHS stated.

"In many cases, indictments and complaints allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided," HHS stated.

HHS explained the arrests:

  • Miami - 46 arrests. Some of the arrests included mental health services in which "beneficiaries who were residents of halfway houses were allegedly threatened with eviction if they did not agree to attend the mental health center."
  • Houston - two arrests that accounted for $62 million in false claims for home health and DME. "One defendant allegedly sold beneficiary information to 100 different Houston-area home health care agencies in exchange for illegal payments."
  • Baton Rouge, La. - 10 arrests related to false claims for home health and DME. One indictment includes a doctor, nurse and five co-conspirators that allegedly billed Medicare for more than $19 million for medically unnecessary or not provided home health and skilled nursing services.
  • Detroit - 18 arrests including 14 defendants that allegedly billed $14 million in false claims as part of a home health scheme.
  • Los Angeles - six arrests.
  • Brooklyn - three arrests.
  • Dallas - two arrests.
  • Chicago - four arrests.

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

For more on the charges, read the HHS press release, please click here.

dr-r-wuebkerTo prepare best for a potential audit from a host of Centers for Medicare & Medicaid Services (CMS) contractors, hospitals must ensure that their utilization review (UR) process is efficient and effective, and that utilization review staff are versed on Medicare conditions of participation (CoP) and other rules and regulations. It is critical that hospitals have a defensible and compliant medical necessity review process in place.

In order to achieve this goal, hospitals must establish and define each UR committee member's role, then execute on those responsibilities. Properly designed, the UR committee can do more than just ensure appropriate hospital and professional service utilization; it can have a beneficial effect on quality of care and overall patient satisfaction. In order to achieve the highest level of compliance, the committee should be composed of several different groups within a hospital, as no one person has the insight to accomplish this alone.

Forming the Committee

The voting members in a UR committee should be physicians who have absolutely no conflict of interest. These physicians cannot have been involved professionally in the care of a patient whose case is being reviewed and can have no direct financial interest in the hospital. Non-physician health professionals and non-medical advisors are also important members of the committee. These members can include case management and administrative staff along with risk management personnel and the board of trustees. It also is highly recommended that executive leaders of the hospital such as the chief medical officer (CMO), chief nursing officer (CNO) and compliance officer stay involved as well.

Ensuring Compliance

Once all UR committee members are in place, it is the responsibility of this group to ensure that hospitals are compliant with government regulations regarding inpatient hospital services by conducting reviews of duration of stays and professional services. The committee must identify areas for improvement as well as best practices as they relate to medical necessity compliance. In order to be compliant with government regulations, a hospital must identify over- and under-utilization of extended stays, avoidable days, and quality issues.

The best way to scrutinize these areas of potential improvement is to screen and sample reviewed cases and compare the data to a larger sample group from similar hospitals.

Sample screening can be achieved in several different ways. A standard place to start is by examining a hospital's quarterly Program for Evaluating Payment Patterns Electronic Report (PEPPER), which identifies outliers of services compared to similar hospitals. Government contractors use data like the information reflected in these reports when making a decision whether to audit.  The UR committee must strive for their PEPPERs to reflect their efforts to remain compliant with CMS.

The Committee at Work

Looking at past practices can help determine a course of action for the future. When cases arise, UR committees need to make quick, educated decisions regarding admissions or continued stay. A complete determination cannot be achieved simply by reviewing a chart, so members must consult with the physician or physicians responsible for the patient's care. If the UR committee disagrees with a practitioner regarding the medical necessity of an admission, the committee can work with the physician to ensure that the patient is placed in the correct level of care. In some cases, even if the attending physician believes that an admission is valid, the committee may disagree and conclude that an inpatient admission is not medically necessary. Since decisions regarding medical necessity ultimately must be made by physicians, physician participation on the UR committee is a necessity in its own right.

The UR committee should meet on a regular basis - monthly meetings are a good starting point - with sub-groups meeting as needed to accomplish specific objectives. The timing of the meetings should be defined in the UR plan.

The key to managing a successful UR committee is to learn from others' successes. The best practices presented in this article have produced positive results for hospitals across the country.  There is no way to prevent an audit, but there are many ways to prepare for one properly. The creation of an educated, dedicated and compliant UR committee is a great place to start.

About the Author

Ralph Wuebker, MD, currently serves as Vice President of Executive Health Resources' (EHR) ACE (Audit, Compliance and Education) Team. This group of physicians conducts audits and regular visits to EHR's client hospitals to provide ongoing education on a variety of topics including Medicare and Medicaid compliance and regulations, medical necessity, Recovery Audit Contractors, utilization review, denials management and length of stay.

Contact the Author

rwuebker@ehrdocs.com

To comment on this article please go to editor@racmonitor.com

Creating and Executing Goals to Form an Effective UR Committee