October 17, 2011

RAC Focuses on Pain Management Providers at Various Audit Levels

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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

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OIG Work Plan Challenges Continue for Physicians

Jana B. Gill, MA, CPC

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