October 16, 2012

Region D RAC Posts Pre-payment Review Issue

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HealthDataInsights, the recovery auditor (RAC) for Region D, will conduct a pre-payment review of medical necessity for MS-DRG 312 (syncope and collapse).

That’s the first issue RACs have posted as part of the new demonstration to cut improper payments that CMS announced last November.

The issue, approved Aug. 27 but posted last week, notes that “DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record.”

While the RAC states that the issue affects all 17 Region D states and three territories, CMS previously has said the pre-payment review is applicable to 11 states: California, Florida, Illinois, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania and Texas.

RAC experts have told DecisionHealth that they expect CMS will make pre-payment reviews a permanent part of the RAC program in all states after the demonstration.

Other facts about the RAC pre-payment review demonstration, according to CMS:

  • RACs and Medicare administrative contractors (MACs) will coordinate to avoid overlap.
  • MACs will send additional documentation requests.
  • Providers have 30 days to send documentation and will “receive determination on their remittance advice within 45 days,” a CMS slide presentation about the demonstration states.

The CMS slide presentation about the pre-payment review demonstration is available here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/downloads/RAC_Prepay_slides.pdf.

HealthDataInsights also posted an issue about reviewing medical necessity for manual wheelchairs and accessories. For more details on that and the pre-payment review, see the charts below.

Acute care

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Pre-payment review of MS-DRG 312 (syncope and collapse)

8/27/12

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. DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MSDRG 312, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.

CMS Pub. 100-02 chapters 1 and 6; CMS Pub. 100-08 chapters 6 and 13; ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM Addendums and coding clinics; OIG DRG Validation Reports, Summaries and Annual Updates, 1989 to current


 

Supplies

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review for manual wheelchairs and accessories

8/20/12

RAC Region D

Manual wheelchairs and accessories must meet basic coverage criteria and subsequent, whether at initial purchase or any point during a rental period as outlined in CMS publications, NCD for mobility-assistive equipment (280.3), local coverage determination (LCD) for manual wheelchair bases (L11454) and CMS policy article for wheelchair manual bases (A25378). Medical documentation will be reviewed to determine that services were reasonable and necessary.

Social Security Act sections 1833(e), 1834 [42 U.S.C. 1395m] (a) Payment for Durable Medical Equipment (1)(E) (i, ii, v), (7) (C) (A) (i, ii, iii), (j) (2) (A) (i, ii, iii) and (B); national coverage determination NCD 280.3;. CMS Pub. 100-08 chapters 3, 4 and 5

About the Author

Karen Long is the editor of Physician Solutions 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

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Karen Long

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