RACs:5 Target Areas

Your Group Needs to Know

Jen Godreau, CPC, CPMA, CPEDCDirector

jenniferg@codinginstitute.com

Understand Alphabet Soup

Acronym Title Area

MAC Medicare Administrative Contractor

MPIC Medicaid Program Integrity Contractor

Fraud

RAC Recovery Audit Contractor Overpayments

ZPIC Zone Program Integrity Contractor

Fraud

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CMS Delays Medicaid RAC Program

Source: CMS Bulletin

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“Out of consideration for state operational issues and to ensure states comply with the provisions of the final rule, we have determined that states will not be required to implement their RAC programs by the proposed implementation date of April 1, 2011.”

When the Medicaid RAC Final Rule is issued later this year, it will indicate the new implementation deadline.

RAC BasicsPurpose: Detect and correct past improper payments

so CMS 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 $1.03 billion in Medicare improper payments.

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RAC Fraud

Source: OIG February Report

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Referred only two cases of potential fraud to CMS

“Because RACs do not receive their contingency fees for cases they refer that are determined to be fraud, there may be a disincentive for RACs to refer potential cases of fraud.”

What Can You Do?

1. Know findings of OIG CERT2. Know findings of RAC Preliminary Program3. Know plan of RAC Implementation Program4. Know the target areas for your contractor5. Identify your weaknesses

Review documentation before paymentsReview documentation postpayment

6. Educate physicians, coders, billers

Prevention Tips

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RAC Preliminary Findings

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Source: RAC Error Report

RAC Preliminary Findings

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Source: RAC Error Report

Top Overpayments!

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IV HydrationRule: Should be billed with a maximum

number of units (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.

Hydration: Initial Code = 1 Unit

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

Logic: Based on the hydration code’s definition, you should report this “initial” code once per patient per date of service

Typically report 96360 only when medically necessary hydration is the lone infusion performed at the encounter.

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

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

1 Unit Maximum Exception

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Can append modifier 59 if circumstances require that two separate IV sites be used Example: The IV in the left arm blows out or

has complications after 31 minutes and another IV is started in the right arm that goes for 32 minutes.

Code: 96360, 96360-59

Guidelines

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• Clear notation should exist for actual start and stop times 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 with medication. An IV push may be coded.

Check for clear notation for actual start and stop times for each bag, route of administration, hydration is performed.

 Check that 31+ minutes to 60 minutes of hydration infusion is recorded for 96360; for intervals of greater than 30 minutes that go beyond one-hour increments, each additional hour is coded with 96361. No modifier is required.

Pull claims that contain a Chemotherapy and an IV hydration code. IV hydration may only be coded if documentation of start and stop times in the record that show the hydrations are given before or after chemotherapy.

Look at claims that contain a Therapeutic Infusion and an IV hydration code. Hydration may only be coded if the hydrations are given before or after the therapeutic infusion.

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

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Action Plan

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Improper Documentation

• “over 1 hour”• 600cc infused with no start or stop times• medically unlikely amounts of medications

versus route (for instance, “NS 400cc per hour flush”)

• “Initial line (INT) removed/hep-lock discharged”• administration times that are marked through

and/or illegible• times recorded that do not make sense (such as

start time 6:39 with stop time 4:19) cannot be coded and thus should not be billed. 

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Know the Facts About Self Audit

If self-audit identifies improper payments, you should:report the improper payments to your MACremit any necessary refunds.

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

Source: RAC FAQs

3 Often Missed Coding Basics Untimed codes, excluding modifiers

KX and 59. Bill one unit of these codes per date of service.

Once in a lifetime procedures, which should be billed just once in a beneficiary’s lifetime.

Pediatric codes that are billed for patients who exceed the age limit defined by the CPT® code.

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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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Once in a Lifetime

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

Code’s Purpose: Onetime AAA screening for Medicare patients referred following an initial preventive physical examination.

Medicare coverage: The patient must meet one of the following risk categories:has a family history of AAAis a man age 65 to 75 who has smoked at least 100

cigarettes in his lifetimeis a beneficiary who manifests other specified risk

factors.

Global Billing of Radiology Codes in the Facility Setting

Region: RAC for Region A (DCS) Professional Component: Owner of the

equipment bills the technical component with modifier TC (Technical component)

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

“Hospital bundling rules exclude payment of radiology services to suppliers of the TC portion of the radiology service for beneficiaries in a patients in a hospital inpatient stay.”

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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.

Source: clm104c13

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Split Billing Values75310 (Radiologic examination, hip, unilateral; complete, minimum of 2 views)

Payment Equation26 + TC = Global

2615%

TC35%

Global50%

Payment

Service

National Rate

26 $11.55

TC $27.52

Global $39.07

CPT© 2011 American Medical Association. All rights reserved.CPT® is a registered trademark of the American Medical Association. All rights reserved.

Source: MPFS 2011

Untimed PT Coding Codes: Untimed therapy codes, such as a PT or OT

evaluation (97001 or 97003) Affected Regions: DCS Healthcare (Part A),

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

Type of Review: Automated Settings: Outpatient & facility PT, OT, SLP Rule: Enter only “one” in the units billed column

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

codes.

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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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Dodge Potential PitfallsDefinition: An untimed code, according to the CPT® code definition,

is one billed irrespective of the time spent on the service. If the code doesn’t have a time indicator, it’s at an untimed code.

Problem: The therapy documentation may include the number of minutes. A coder who isn’t 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 there’s an overpayment.

Solution: Alert billers to this potential snag.Problem: Medicare allows you to use the 59 modifier to

identify situations where you provided therapy to more than one body site. But you can’t use a modifier 59 for an untimed code.

Solution: Know your guidelines.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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Look for Duel Untimes Service Appeals, Adjustments Check denials of untimed code with another untimed code

No prohibition against billing two untimed codes – the approved RAC issue is for two units of an untimed code. Appeal these denials.

Example of an acceptable claim: A speech swallowing evaluation and a speech swallowing service on the same claim.

Expect DCS (Region A) refunds Letters were mailed to affected providers the first week of February

2011 with notification of the incorrect edit resulting in the overturned automated reviews. 

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

 Steps: Allow time for adjustments.  Do not need to appeal.

Source: DCS Provider Notice, Feb. 16, 2011

Neulasta Admin CodingCode: J2505 (Injection, pegfilgrastim, 6 mg)Affected Areas: AllSetting: Physician, OutpatientType of Review: AutomatedGuideline: Report 1 unit of Pegfilgrastim for per

6 mg injectedOld way: Prior to Jan. 1, 2004, Neulasta’s 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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CPT© 2011 American Medical Association. All rights reserved.CPT® is a registered trademark of the American Medical Association. All rights reserved.

ResourcesAHANews, “CMS delays Medicaid RAC implementation.” Feb. 18, 2011.

http://www.ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_021811_RAC&domain=AHANEWS

Cheryl E. Servais, MPH, RHIA, “IV Hydration Documentation and Coding Could Be Vulnerable to 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.pdf

CMS, “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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ResourcesCMS RAC Web site

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

DCS Healthcare. “Important Provider Notice:  February 16, 2011.”http://www.dcsrac.com/PROVIDERPORTAL.aspx

Deborah Dorton, 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

Deborah Dorton, 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.pdfOIG, “Review of Medicare Part B Claims for Neulasta – Wisconsin Physicians

Service for the Calendar Years 2004 Through 2007.” June 2009.http://www.oig.hhs.gov/oas/reports/region5/50900070.pdf

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ResourcesJan Milliman, MA, HCS-D, COS-C, “NEWS BRIEFS: Careful — RACs Are Watching

Your Untimed 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 Part B 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=neulastaTorrey 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+racTorrey Kim, MA, CPC, CGSC, “RAC AUDITS: RAC Contractors List 7 Audit Issues

on Their Radar 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+racs04/10/2023 28

ResourcesZPIC Information

http://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 Technologies and Solutions, Inc.

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

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

Connolly Healthcare

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, N Marianas

HealthDataInsight, Inc.

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

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RAC Sites

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