August 4, 2009

The RACs Begin to Roll: Seven CMS Approved Audit Issues

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It's finally starting. There are now seven approved issues for at least one RAC's automated review process.

 

Connolly Healthcare, the RAC Contractor for Region C, is the first RAC to have posted CMS-approved issues on its Web site. All seven issues posted affect outpatient hospital and physician providers.

 

The issues noted below should serve as an impetus for hospital and physician providers alike in taking "practice" RAC audits to the next level. It is likely that these issues will appear in the other Region C states, so even if you are not in South Carolina, it is a good idea to investigate your organization's risk profile in the following posted areas.

 

Seven Approved Issues

 

Blood Transfusions, with CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one (1) per session, regardless of the number of units transfused on any given date of service.

 

According to Carla Engle, MBA and product manger for MediRegs, a Wolters Kluwer company, "CMS on March 4, 2005, issued long-awaited Medicare blood billing guidelines for hospital outpatient departments. As stated in the original 2001 guidance, these 2005 guidelines also address that hospital outpatient departments may bill Medicare for the transfusion procedure only once per day, regardless of the number of units or different types of blood products transfused."

 

Untimed Codes For CPT Codes (excluding modifiers KX, and 59), for which a procedure is not defined by a specific time frame (untimed codes), the provider should enter a one (1) in the units-billed column per date of service.

 

According to Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, "this is a rehab issue, although not stated as such. The CMS references listed on the Connolly Web site are from the Medicare Claims Processing Manual chapter on hospital outpatient rehab, including CORFs and rehab agencies, with another reference to Transmittal 19 which gave direction to billing rehab service codes." Beckley predicted that this issue would be among the first rehab issues approved for automated reviews in "Likely Outpatient Rehab RAC Targets - Hiding in Plain Sight", appearing in the July 15th issue of the RACMonitor.

 

IV Hydration Therapy Based on the definition of CPT 90760 (excluding claims modifier-59), the maximum number of units should be one (1) per patient, per date of service. Beginning 1.1.09, code 90760 was replaced with code 96360.

 

According to Ashley L. Brandon, MBA, RHIA, CCS, internal coding audit coordinator for Precyse Solutions, "IV hydration therapy documentation must be clearly noted with actual start and stop times for each bag, the route of administration, and sufficient documentation to decipher whether a flush versus hydration (exists)."

 

Examples of documentation that cannot be charged are notations of "Over 1 hour" as ordered; INT removed/hep-lock discharged; 800cc infused with no start or stop times; marked through and/or illegible administration times; times that do not make any sense (i.e. start time 10:09 with stop time 9:19); and medically unlikely amount of med versus route example "NS 200cc per hour flush."  And finally, says Brandon, "if it's not documented, it's not done."

 

Bronchoscopy Services CPT Codes 31625, 31628 and 31629 should be billed with a maximum number of units of one (1) per patient, per date of service (excluding claims with modifier 59) and reported with one unit per date of service.

 

Once-in-a-Lifetime Procedures By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime.

 

Pediatric Codes Exceeding Age Parameters Newborn/Pediatric CPT codes being applied/billed for patients who exceed the age limit defined by the CPT code.

 

J2505: Injection, Pegfilgrastim, 6 mg By definition, HCPC Code J2505 represents 6 mg per unit. The code should be billed at one (1) unit per patient, per date of service.

 

As previously stated by CMS, there is a maximum lookback period of three years, effective October 2007 moving forward. Connolly will be using InterQual and Milliman Care Guidelines as tools to assist them in RAC reviews.

 

In the listing for each issue Connolly also has referenced CMS Manuals as well as other authorities providers can reference to ensure compliance with the regulations.

 

"It is a good idea for providers to review the references provided and construct compliance audits for their organizations, including those under attorney-client privilege, as appropriate," said Beckley.

 

The RACs began this process with the initiation of town-hall meetings this past spring. Connolly hosted some of the first town-hall meetings in South Carolina last March 20, followed by meetings in Florida, Colorado and New Mexico. Look for Connolly to have these same issues approved in those states as well.

 

Let the fun begin.

 

Contributing to this article were Nancy Beckley, MS, MBA, CHC, Ashley L. Brandon, MBA, RHIA, CCS, Carla Engle, MBA, Dennis Jones, and Cheryl E. Servais, MPH, RHIA.

Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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