RAC Best Preventions

8/7/2019 RAC Best Preventions

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5 Target Areas5 Target Areas

Your Group Needs to KnowYour Group Needs to Know

Jen Godreau, CPC, CPMA, CPEDC

Director

[email protected]


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Acronym Title Area

MAC Medicare Administrative ContractorMPIC Medicaid Program Integrity

ContractorFraud

RAC Recovery Audit Contractor Overpayments

ZPIC Zone Program Integrity Contractor Fraud

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Out of consideration for state operational issuesand to ensure states comply with the provisions

of the final rule, we have determined that stateswill not be required to implement their RACprograms by the proposed implementation dateof April 1, 2011.

When the Medicaid RAC Final Rule is issued

later this year, it will indicate the new

implementation deadline.


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Purpose: Detect and correct past improper payments soCMS and the MACs can prevent such problems in the

future.Employer: RACs are hired as contractors by the

government, and they can collect contingency fees.

Scope: The maximum RAC lookback period is three years,

and they cannot review claims paid prior to Oct. 1, 2007.Recovery: Between 2005 and 2008, RACs involved in the

original demonstration project recovered over $1.03billion in Medicare improper payments.

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Referred only two cases ofpotential fraud to CMS

Because RACs do not receive theircontingency fees for cases theyrefer that are determined to befraud, there may be a disincentive

for RACs to refer potential cases offraud.


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1. Know findings of OIG CERT

2. Know findings of RAC Preliminary Program3. Know plan of RAC Implementation Program

4. Know the target areas for your contractor

5. Identify your weaknesses

y Review documentation before paymentsy Review documentation postpayment

6. Educate physicians, coders, billers

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Rule: Should be billed with a maximum number ofunits (1) per patient per date of service

Setting: Outpatient Hospital, PhysicianAffected Areas: IL, IN, KY, MI, MN, OH, WI (MAC

Region B), Connelly Consulting (MAC Region C)

Codes: 90760 (deleted), 96360 (effective CPT 2009)

Descriptor: Hydration IV infusion , initial

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CPT 2011 American Medical Association. All rights reserved.

CPT is a registered trademark of the American Medical Association. All rights reserved.


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96360 (Intravenous infusion; initial, 31 minutes to 1 hour)

Logic: Based on the hydration codes definition, youshould report this initial code once per patient per date

of serviceTypically report 96360 only when medically necessary

hydration is the lone infusion performed at theencounter.

Exception: Can append modifier 59 (Distinct proceduralservice) for a legitimate reason

Bottomline: Reporting 96360 more than once on a singledate of service is highly unlikely.


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Can append modifier 59 if circumstances requirethat two separate IV sites be used

y Example: The IV in the left arm blows out or hascomplications after 31 minutes and another IV isstarted in the right arm that goes for 32 minutes.

y Code: 96360, 96360-59


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Clear notation should exist for actual start and stoptimes for each bag, the route of administration, and

whether a flush or hydration is performed. If only a flush (clearing of lines) is performed, the

procedure is not coded unless the flush occurs withmedication. An IV push may be coded.


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Check for clear notation for actual start and stop times

for each bag, route of administration, hydration isperformed.

Check that 31+ minutes to 60 minutes of hydrationinfusion is recorded for 96360; for intervals of greaterthan 30 minutes that go beyond one-hour increments,each additional hour is coded with 96361. No modifier isrequired.

Pull claims that contain a Chemotherapy and an IV

hydration code. IV hydration may only be coded ifdocumentation of start and stop times in the record thatshow the hydrations are given before or afterchemotherapy.

Look at claims that contain a Therapeutic Infusion andan IV hydration code. Hydration may only be coded ifthe hydrations are given before or after the therapeuticinfusion.

Correct claims that contain a IV hydration and bloodtransfusion code. IV hydration codes ARE NOT codedand/or reported with blood transfusion codes,regardless of when the IV hydration is administered.

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over 1 hour

600cc infused with no start or stop times

medically unlikely amounts of medications versusroute (for instance, NS 400cc per hour flush)

Initial line (INT) removed/hep-lock discharged

administration times that are marked throughand/or illegible

times recorded that do not make sense (such as starttime 6:39 with stop time 4:19) cannot be coded andthus should not be billed.


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If self-audit identifies improper payments, you should:

report the improper payments to your MAC

remit any necessary refunds.

The RAC will be aware of the adjustment, butthe refund does not preclude future review.


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Untimed codes, excluding modifiers KXand 59. Bill one unit of these codes per date

of service. Once in a lifetime procedures, which

should be billed just once in a beneficiaryslifetime.

Pediatric codes that are billed forpatients who exceed the age limit defined bythe CPT code.

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G0389 (Ultrasound B-scan and/or real time with imagedocumentation; for abdominal aortic aneurysm [AAA] screening)

Codes Purpose: Onetime AAA screening for Medicare

patients referred following an initial preventive physicalexamination.

Medicare coverage: The patient must meet one of thefollowing risk categories:

y

has a family history of AAAy is a man age 65 to 75 who has smoked at least 100 cigarettes

in his lifetime

y is a beneficiary who manifests other specified risk factors.


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Region: RAC for Region A (DCS)

Professional Component: Owner of the

equipment bills the technical componentwith modifier TC (Technical component)

Problem: FIs and MAC A/Bs include TCcomponent in hospital PPS payment.

Hospital bundling rules exclude payment ofradiology services to suppliers of the TCportion of the radiology service forbeneficiaries in a patients in a hospitalinpatient stay.

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75310 (Radiologic examination, hip, unilateral; complete, minimum of 2 views)

Payment Equation

26 + TC = Global2615%

TC35%

Global50%

Payment

Service National Rate

26 $11.55

TC $27.52

Global $39.07




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Codes: Untimed therapy codes, such as a PT or OTevaluation (97001 or 97003)

Affected Regions: DCS Healthcare (Part A),

Connolly Healthcare (Region C, SC only) Health DataInsights, Inc., (Region D, all 20 states in jurisdiction)

Type of Review: Automated

Settings: Outpatient & facility PT, OT, SLP

Rule: Enter onlyone in the units billed column per

date of serviceRAC will not consider modifiers KX or 59 in these CPT

codes.

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Definition: An untimed code, according to the CPT codedefinition, is one billed irrespective of the time spent on the service.If the code doesnt have a time indicator, its at an untimed code.

Problem: The therapy documentation may include thenumber of minutes. A coder who isnt familiar with the codes

may bill for four units or an hour for an untimed code. If the MAC

or FI system pays it by mistake, then theres an overpayment.

Solution: Alert billers to this potential snag.

Problem: Medicare allows you to use the 59 modifier to

identify situations wh

ere you provided therapy to more t

han onebody site. But you cant use a modifier59 for an untimed code.

Solution: Know your guidelines.




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Check denials of untimed code with another untimed codey No prohibition against billing two untimed codes the approved RAC issue is

for two units of an untimed code. Appeal these denials.

y Example of an acceptable claim: A speech swallowing evaluation and a

speech swallowing service on the same claim. Expect DCS (Region A) refunds

y Letters were mailed to affected providers the first week of February 2011 withnotification of the incorrect edit resulting in the overturned automatedreviews.

y Adjustments may take up to 4 weeks. Providers should receive a remittanceadvice that will show reason code N432 for the repayment of any related

recouped amounts.

Steps:

Allow time for adjustments.

Do not need to appeal.


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Code: J2505 (Injection, pegfilgrastim, 6 mg)Affected Areas: AllSetting: Physician, Outpatient

Type of Review: AutomatedGuideline: Report 1 unit of Pegfilgrastim for per

6 mg injectedOld way: Prior to Jan. 1, 2004, Neulastas code

descriptor (Q4053) indicated you should report

one unit per 1 mg.New way: The current definition requires one

unit per 6 mg.

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AHANews, CMS delays Medicaid RAC implementation. Feb. 18, 2011.http://www.ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANews

NowArticle/data/ann_021811_RAC&domain=AHANEWS

Cheryl E. Servais, MPH, RHIA, IV HydrationDocumentation and Coding Could Be Vulnerableto RAC Audits Part 1. RACMonitor.com. Aug. 12, 1009.

http://racmonitor.com/news/12-from-the-editor/209-iv-hydration-documentation-and-coding-could-be-vulnerable-to-rac-audits-part-1.html

CGI Federal,IV-Hydration.http://racb.cgi.com/IssueDetail.aspx?isd=2

CMS Bulletin, CPI-B-11-03. Feb. 1, 2011.

https://www.cms.gov/MedicaidIntegrityProgram/Downloads/6411racdelay.pdf

CMS, Medical Claims Processing Manual, Chapter 13.http://www.cms.gov/manuals/downloads/clm104c13.pdf

CMS Manual System, Pub 100-04 Medicare Claims Processing. Nov. 17, 2006.

http://www.cms.gov/transmittals/downloads/R1113CP.pdfCMS, MLNMattersArticles SE1028.

https://www.cms.gov/MLNMattersArticles/downloads/SE1028.pdf

CMS, RAC Evaluation Report.

http://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf

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CMS RAC Web sitewww.cms.hhs.gov/RAC/Downloads/RAC%20Expansion%20Schedule%20Web.pdf

DCS Healthcare. Important Provider Notice: February 16, 2011.

http://www.dcsrac.com/PROVIDERPORTAL.aspx

DeborahDorton, JD, MA, CPC, CHONC, Focus on Transfusion, Hydration, and J2505 Before RACs Do. Oncology and Hematology Coding Alert. October 2009.

http://www.supercoder.com/articles/articles-alerts/onc/focus-on-transfusion-hydration-and-j2505-before-racs-do/?zoom_highlight=96360+racs

DeborahDorton, JD, MA, CPC, CHONC, Red Flag: G0389 May Be a Potential RAC Target.Oncology and Hematology Coding Alert. September 2009.

http://www.supercoder.com/articles/articles-alerts/rca/red-flag-g0389-may-be-a-potential-rac-target/?zoom_highlight=radiology+rac

Federal Register, Proposed Rules. Medicaid Program; Recovery Audit Contractors. Nov. 10,

2010.http://edocket.access.gpo.gov/2010/pdf/2010-28390.pdf

OIG, Review of Medicare Part B Claims for Neulasta Wisconsin Physicians Service for theCalendar Years 2004 Through 2007. June 2009.

http://www.oig.hhs.gov/oas/reports/region5/50900070.pdf

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Jan Milliman, MA, HCS-D, COS-C, NEWS BRIEFS: Careful RACs Are Watching YourUntimed Therapy Codes. Physical Medicine & Rehabilitation. September 2009.

http://www.supercoder.com/articles/articles-alerts/pmc/news-briefs-careful-racs-are-watching-your-untimed-therapy-codes/?zoom_highlight=physical+therapy+rac

Jan Milliman, MA, HCS-D, COS-C, Billing: Make Time to Target Untimed Codes on Your PartB Therapy Claims. Physical Medicine & Rehabilitation. April 2010.

http://www.supercoder.com/articles/articles-alerts/pmc/billing-make-time-to-target-

untimed-codes-on-your-part-b-therapy-claims/?zoom_highlight=physical+therapy+rac

Torrey Kim, MA, CPC, CGSC, In other news... Part B Insider. June 2010.

http://www.supercoder.com/articles/articles-alerts/pbi/in-other-news...-102017/?zoom_highlight=neulasta

Torrey Kim, MA, CPC, CGSC, In other news... Part B Insider. September 2010.

http://www.supercoder.com/articles/articles-alerts/pbi/in-other-news...-102988/?zoom_highlight=physical+therapy+rac

Torrey Kim, MA, CPC, CGSC, RAC AUDITS: RAC Contractors List 7 Audit Issues on TheirRadar Screens. Part B Insider. August 2009.

http://www.supercoder.com/articles/articles-alerts/pbi/rac-audits-rac-contractors-list-7-audit-issues-on-their-radar-screens/?zoom_highlight=96360+racs

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ZPIC Informationhttp://www.cms.gov/manuals/downloads/pim83c04.pdf

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Region States Contractor Approved Issues Page

A CT, DC, DE, MA,MD, ME, NH, NJ,NY, PA, RI, VT

DCS Healthcare http://www.dcsrac.com/IssuesUnderReview.aspx

B IL, IN, KY, MI, MN,OH, WI

CGI Technologiesand Solutions, Inc.

http://racb.cgi.com/Issues.aspx

C AL, AR, CO, FL,GA, LA, MS, NC,NM, OK, SC, TN,TX, VA, WV

ConnollyHealthcare

http://www.connolly.com/healthcare/pages/ApprovedIssues.aspx

D AL, AZ, CA, HI, IA, ID,KA, KS, MO, ND, SD,UT, WA, WY, Guam,

Am Somoa, NMarianas

HealthDataInsight,Inc.

https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx

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