Updated on: January 29, 2013

The RAC Race Has Begun: There is Still Time to Turkey Trot Your Way to Compliance Success

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Original story posted on: November 17, 2009

nbeckleyThe RAC program is now in full swing, and as reported in a special alert earlier this month, Florida providers have been receiving demand letters from Connolly, the RAC for Region C. Based on input from a provider that was willing to share information, one initial demand letter pertained to billing of untimed codes in units greater than one. 

Subsequently, the provider reported having received additional demand letters denying an untimed code that was billed appropriately, but on the same day as another appropriately billed untimed code that was on the same claim.

In what is regarded as likely being the first reported "sighting" of a RAC demand letter under the permanent program, inquiring minds may want to know a bit more about the facts.

Without further pause, here is what is known about this specific rehab provider's demand letter situation.

  • In early August, Connolly became the first RAC to post CMS-approved issues for automated review, a list that included blood transfusions, untimed codes, IV hydration therapy, bronchoscopy services, one-in-a-lifetime procedures, pediatric codes exceeding age parameters and J2505: Injection, Pegfilgrastim, 6 mg.

  • Protocol regarding the issue of untimed codes was described by the following: "CPT Codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service."

  • The provider's first letter was dated in the second week of October, although the referenced spreadsheet attached to the letter had a run date of the first week of September, indicating a one-month lag. It is clear that productive RAC automated reviews were underway in early September.

The initial demand letters were consistent with the CMS-approved automated review of untimed codes and consistent with reference citations found in the CMS Medicare Benefits Policy Manual's references to Transmittal 1019 and Section 20.2 of Chapter 5.   The provider acknowledged that an overpayment had occurred and took steps, including staff training and systems monitoring, to ensure that proper procedures are in place to prevent this error from occurring in the future.

According to both referenced citations, "the codes that are allowed one unit for ‘Allowed Units' ..... may be billed no more than once per provider, per discipline, per date of service, per patient."  However, subsequent demand letters cited the same references demanding repayment of claims in which two separate and distinct untimed codes appeared. A swallowing treatment session was billed on the same day as the swallowing evaluation, each service having been performed during separate time frames.

In CMS regulatory citations for untimed codes, there is no reference to, or prohibition on, billing for two untimed codes, and the National Correct Coding Initiative's (CCI Edits) mutually exclusive or column 1/column 2 edit tables do not contain the code pairs in question. An appeal has been filed, and pending its outcome, there may be further implications for the rehab industry on the RAC program interpretation of untimed codes.  An industry response may be in order, and that certainly is not without precedence in the rehab field as noted in the RACMonitor.com feature article on the FAIR, which is challenging the opening of claims without cause after one year.

Stay tuned for updates, and if you have received demand letters related to the untimed codes, let's talk turkey.......

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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