September 16, 2009

Local Coverage Determinations: Scrapbooking Your Way to Success in a RAC World

By

nbeckley

I'm not much of a crafter. In fact, I have been hoping for years to compile a collection of my grandmother's Croatian cooking recipes as a gift for my mother, which in turn would be handed down to my daughter, but I just can't seem to get started.

Then I found myself recommending to a large multi-state provider that it needed to create a scrapbook of its local coverage determinations for all the jurisdictions in which it provides service - a process that involves five states, three Medicare contractors, current local coverage determinations (policies), transitional policies and retired policies. During the past several years this provider had dealt with updated policies under a current carrier, transitions to two new Medicare Administrative Contractors (MACs), legacy LCDs, and a whole lot of confusion.

Now that the RAC process of automated review is well underway, with CMS-approved topics listed by three of the four RACs, it is critically important for all providers and suppliers to have a collection of all the pertinent policies they have been subject to since October 07.  When denial letters eventually start pouring in, better preparation will facilitate timely internal responses and assist in expediting appropriate appeals.

So, am I recommending that your RAC teams head to Michaels this weekend and pick up scrapbooking supplies? Hold that thought. According to Wikipedia, a "commonplace book," originating in the 15th century, was essentially a "scrapbook filled with items of every kind: medical recipes, quotes, letters, poems, tables of weights and measures, proverbs, prayers, legal formulas. Commonplaces were used by readers, writers, students, and humanists as an aid for remembering useful concepts or facts they had learned. Each commonplace book was unique to its creator's particular interests."

"Commonplace" is a translation of the Latin term locus communis, which means "a theme or argument of general application," according to Wikipedia. So that is what is in order for all providers in their quest for readiness regarding the RAC audits, and particularly in anticipation of the denials that will prompt appeals.

Let's take a look at an example from a WPS policy that was to be effective on Sept. 15, contrasted with a policy that was in effect prior to that date. In the new policy, it is stated that no more than 1-2 units of therapeutic exercise (CPT 97110) would be expected during a session that included neuromuscular rehab (CPT 97112).

However, in the old policy there is no mention of a 1-2 unit cap on 97110. Why is this of significance?  First, 97110 is the most frequently used therapy code, and often is used as a code to capture the majority of a patient visit. It is considered by many to be a "catch-all" code when no other more specific code applies, and it would not be unusual for a therapist to bill three units, and often times four units, during a therapy session consisting of 4-6 units billed. Secondly, and more importantly in the RAC perspective, this issue can be reviewed automatically - it is simply a matter of performing an electronic automated claims review to ensure that the units billed per date of service do not exceed two units. This represents a minor variation on the already CMS-approved issue of untimed codes, or those codes that cannot be billed in units greater than one, according to the CPT definition of the code.

The Nitty-Gritty

Let's get to the nitty-gritty - if you receive a RAC denial for billing more than two units of 97110 for service dates PRIOR to Sept. 15, that denial can be appealed successfully based upon the presentation of the proper documentation from the legacy policy. If the denial is for a service date of Sept. 15 going forward, the matter is not appealable, based on current policy. Remember, in automated reviews the issue of medical necessity is not at issue, so that is not up for discussion unless the policy specifically allows for additional units that are supported by documentation in the medical record.

Commonplace RAC Book

Now back to the scrapbook - ok, let's call it the commonplace book. Here are my recommended steps for compiling your essential RAC commonplace book.

  • Compile a list of all fiscal intermediaries, carriers and Medicare Administrative Contractors your organization has had during the past three years.

  • For each Medicare contractor, identify all the local coverage determinations and policies that applied to services offered. Save an electronic file and print out a copy for your commonplace book.

  • Having a hard time finding a policy that is no longer in effect? Check your contractor's Web site for a listing of legacy policies. Highmark provides a great example of what I am talking about - it is very organized, offering legacy policy numbers and the effective dates: http://www.highmarkmedicareservices.com/policy/legacy/b-pa.html

  • The CMS Web site also has a search function on its policy page for archived policies:  http://www.cms.hhs.gov/mcd/search.asp?clickon=search When using this function you can search by policy number or by descriptive words.

  • Index your RAC commonplace book by policy, and under a tab for each policy topic insert the current policy as well as all the legacy policies to which you have been subject.

  • Identify a champion for each policy that exists - legacy and current.

  • Invite your champions to a RAC commonplace book party (this can be a cyberspace meeting, such as a Webinar). Explain their critical roles in mastering the policies for which they are responsible, and have them dissect each policy for associated RAC risks - starting with potential targets for automated reviews, then moving on to at-risk areas for complex medical reviews.

  • The results of the individual policy risk assessments should form the cover chapter of your RAC commonplace book and will serve as a representative RAC risk assessment, with the subsequent chapters of current policies and legacy policies forming your first line of appeal defense.

  • By the way, when these steps are finished you also will have in your hands a great list of audit topics to cover.

So you might not need to head to Michaels for scrapbooking supplies this weekend, but if it helps any team members in compiling their section of your RAC commonplace book, by all means encourage the use of creative papers, rickrack borders and pictures.

I am eager to hear of your efforts in creating a RAC commonplace book. Let me know how it is coming along, problems you have encountered, and stories of success.

By the way, my favorite Croatian dish is chicken paprikash, and the next time I make it I am going to take a picture to display with the recipe - and put it in the scrapbook I finally started this week.

Laku noch and dobar tek!

About the Author

Nancy Beckley is a co-founder and President of Bloomingdale Consulting Group, Inc., providing consulting services to the rehab professional. Nancy is certified in Healthcare Compliance by the Healthcare Compliance Board, and serves on the Part A and Part B Provider Outreach Education and Advisory Panel for First Coast Services Options (Florida Medicare). She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities.

Contact the Author

nancy@bloomingdaleconsulting.com

Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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