Updated on: January 31, 2013

Watch for Contractors to Install RAC-identified Edits

By
Original story posted on: February 6, 2012

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The multi-carrier system will install edits for certain services that recovery auditors (RACs) identified as having "significant improper payments."

The implementation date is July 2, according to a Jan. 26 CMS transmittal.

Look for the following edits, which are the results of the RAC-identified improper payments, the transmittal states:

  • Billing E/M services unrelated to pulmonary diagnostic tests without modifier 25 - RACs identified overpayments for E/M services (99211-99215) billed without modifier 25 on the same date of services as a pulmonary diagnostic procedure (94010-94799).
  • Billing initial IV hydration codes more than once per day per beneficiary - The RAC demonstration and national program identified the problem. "When reporting services for IV hydration, the initial code should be billed once for the initial infusion lasting up to one hour," the transmittal states. "The additional code should be added to the claim for each additional hour the hydration is infused." The codes involved are 96413, 90765, 96365, 90763 and 96369.
  • Billing CPT codes for new patients who have received office-based face-to-face services within three years - "New patients" are beneficiaries who have not received services from a physician or physician group practice in three years. The codes involved are 99201-99205 and 99341-99345.
  • Billing without modifier 62 when two surgeons perform the surgery - Both must bill using modifier 62.

RAC Posts Two Issues

HealthDataInsights, the Region D RAC, posted two inpatient hospital issues this week about abdominal procedures and spinal procedures. For more, see the chart below.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - abdominal procedures (DRG 326, 335, 405, 406, 799, 800, 801)

1/29/12

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.

CMS Pub. 100-02, chapters 1, 6; CMS Pub. 100-08, chapter 6

Acute inpatient hospitalization - spinal procedures (DRG 028, 029, 030, 453, 454, 455, 491)

1/29/12

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.

CMS Pub. 100-02, chapters 1, 6; CMS Pub. 100-08, chapter 6

 

About the Author

Karen Long is the compliance product manager 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

Reference:

http://www.cms.gov/transmittals/downloads/R1031OTN.pdf.

Karen Long

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