March 26, 2013

Drill Down: What a Provider Should Do With Each Approved RAC Issue

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EDITOR’S NOTE: Dr. Margaret Klasa is the medical director for Context4Healthcare. This article is the first in a weekly series called: “Drill Down,” in which Dr. Klasa drills down on crucial RAC issues.

The key to getting in step with the RAC contractors is to have a good team in place and responsibilities clearly defined for each team member. Depending on the size of your department or practice, your RAC team may consist of several members, or just a single person, for smaller organizations. The first step is to assign a designated RAC team member to check the RAC contractor websites on a daily basis. Approved issues are posted throughout the month. Issues can be filtered down by provider type and date posted to see if issues are posted that pertain to your practice setting. If an issue is listed that pertains to your practice, there are several options. If an issue type is automated, it is based on claim data and can be directly addressed. For example:

RAC Region A contractor, Performant, has posted an automated review issue on 3/19/13: EMG and Nerve Conduction Studies for the following states: PA, MD, DC, NJ, and DE. This issue is based on the Local Coverage Determination (LCD) policy with an original effective date of 5/28/2009 and its latest revision of 1/1/2013. The issue is that claims are being paid by the Medicare Carrier Novitas for diagnoses that are not in the LCD policy. There is only one diagnosis link to procedure 95905 Motor and Sensory Nerve Conduction and that is 354.0 Carpal Tunnel Syndrome that supports Medical Necessity. The other 25 EMG and Nerve Conduction tests included in this policy can be used with the 150+ diagnoses codes listed under the ICD-9 Codes that Support Medical Necessity.

So let’s drill down to see what we can do to support our providers.  This particular LCD L29547 has 22 pages if you print it off the CMS website.

  • The team should review the policy and note the revision history and explanation.
  • Identify the diagnosis allowed along with the appropriate procedural link. If using a vendor, make sure you have tested the link against your claim data and report any variances.
  • Review the Coverage Guidelines section of the policy where it outlines utilization. In this policy, it allows the procedure to only be performed once per year per extremity for carpal tunnel, and it cannot be billed at the same time as any other nerve conduction testing on the same day.
  • Educate the staff regarding this RAC target (this means your provider as well).
  • Review prior claims in your database as well as current claims for the targeted links.
  • Pull the reports on claims already paid or in the system to review and check that utilization is supported.
  • Educate the providers whose billing is at risk of future audits.

The only way to minimize risk for this automated review is to analyze your claims data against the policy, including any revisions, and educate your team.

Now, let’s examine recent postings of approved issues. 

March Approved Issues

RAC Region A Performant

DME Claim Types

  • Osteogenesis stimulators – JA. Potential incorrect billing occurred when claims for Osteogenesis Stimulators were billed without an ICD-9-CM code supporting medical necessity and without all other required criteria described in NHIC’s Local Coverage Determination (LCD) L11501 and related article (A35349).

Hospital Outpatient Claim Types

  • Cardiovascular nuclear medicine – J13. Potential incorrect billing occurred for claims billed with ICD-9-CM codes that are not listed by National Government Services (NGS) Local Coverage Determination (LCD) L26859 (related article A46181) as medically necessary.
  • Nerve conduction studies (NCS) – Maximum units – J13. Potential incorrect billing occurred for claims reporting CPT codes 95900 and 95904 for units in excess of what is medically necessary per utilization guidelines outlined in National Government Services (NGS) Local Coverage Determination (LCD) L26869 and related article A51823.

 Physician/Non-physician Practitioner Claim Types

  • Nerve conduction studies (NCS) – Maximum units – J13 Potential incorrect billing occurred for claims reporting CPT codes 95900 and 95904 for units in excess of what is medically necessary per utilization guidelines outlined in National Government Services (NGS) Local Coverage Determination (LCD) L26869 and related article A51823.
  • Electromyography (EMG) and Nerve Conduction Studies – Diagnoses – J12 Potential incorrect billing occurred for Electromyography (EMG) and Nerve Conduction Studies claims billed with ICD-9-CM codes that are not listed by Novitas Local Coverage Determination (LCD) L29547 as diagnosis codes that support medically necessity.

 

RAC Region B CGI

Inpatient Claim Types 

  • Red Blood Cell Disorders w/o MCC MS-DRG 812 (Medical Necessity) 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.
  • Alcohol/Drug Abuse or Dependence MSDRG 895, 896, and 897 (Medical Necessity) 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.
  • Major Male Pelvic Procedures MSDRG 707 and 708 (Medical Necessity) 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.
  • Mental Diseases and Disorders MDC 19 MS-DRGs 880-887 (Medical Necessity) 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. 

RAC Region C Connolly

Carrier

  • Non-waived and PPM level CLIA tests – C001202012 (For Palmetto states) Providers are incorrectly billing for non-waived and PPM level CLIA tests.
  • Zoledronic acid, (Reclast) – Dose vs. Units Billed – (Underpayment) Zoledronic acid, (Reclast) represents 1 mg per unit and should be billed one (1) unit for every 1 mg per patient.
  • Tysabri (J2323 – Injection, natalizumab, 1 mg), dosed too frequently As per FDA approved drug labeling, the maximum recommended dose of Tysabri (J2323 - Injection, natalizumab, 1 mg) is 300 mg administered at a frequency of 1 infusion no more than every 4 weeks.

Outpatient Hospital Claim Types

  • Tysabri (J2323 - Injection, natalizumab, 1 mg), dosed too frequently As per FDA approved drug labeling, the maximum recommended dose of Tysabri (J2323 - Injection, natalizumab, 1 mg) is 300 mg administered at a frequency of 1 infusion no more than every 4 weeks.

Non-Covered use of Arpetitant (J8501) Coverage for aprepitant (J8501) is predicated by its use as the three-drug combination of aprepitant, a 5-HT3 antagonist and dexamethasone, and must be used in conjunction with one or more specified chemotherapeutic agents.

RAC Region D HDI

  • No new issues posted since 1/9/2013 Blood Glucose Monitor Device Bundling for DME Claim Types.

I’ll return next Tuesday with another edition of “Drill Down.” 

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding with an emphasis on clinical and regulatory guidelines for Medicare and Medicaid and commercial payers. 

Contact the Author

Margaret.Klasa@context4.com

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

Margaret Klasa, DC, APN, Bc

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