Since October 2009, when Medicare’s fee-for-service Recovery Audit Contractor (RAC) Program went nationwide, health care providers have returned $313.2 million in alleged Medicare overpayments and received $52.6 million in Medicare underpayments, according to a new report from the Centers for Medicare & Medicaid Services (CMS). The report also identifies the top overpayment issues in each of the four RAC regions nationwide.
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April 29th, 2011
Internal audits promote healthy medical coding practices and deter Recovery Audit Contractors (RACs) from knocking on your door in search of improper Medicare payments. What should you look out for? A good place to start is to monitor what the four RACs are monitoring. RACs are required to post new issues under review on their websites. Three RACs just posted new issues in May.
DCS Healthcare Services
DCS, RAC for jurisdiction A (District of Columbia, Conn., Mass., Maine, Del., N.J., N.Y., N.H., Pa., R.I., Vt.), posted the following new Medicare severity diagnosis-related groups (MS-DRG) validation issues pertaining to inpatient hospitals (Medicare Part A) on May 11:
Note: At this time, medical necessity is excluded from review.
MS-DRG Validation for Liver Transplant
MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewers will validate for MS-DRG 006; principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the MS-DRG.
For guidance, see: ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM Addendums and Coding Clinics; Medicare Program Integrity Manual chapter 6.5.3, section A-C DRG Validation Review; Uniform Hospital Discharge Data Set (UHDDS) – Reporting of Inpatient Data Elements, July 31, 1985; Federal Register (Vol. 50, No. 147), pages 31038- 31040.
MS-DRG Validation for Heart Transplant
MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewers will validate for MS-DRG 002; principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the MS-DRG.
For guidance, see: ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM Addendums and Coding Clinics; Medicare Program Integrity Manual chapter 6.5.3, section A-C DRG Validation Review; Uniform Hospital Discharge Data Set (UHDDS) – Reporting of Inpatient Data Elements, July 31, 1985; Federal Register (Vol. 50, No. 147), Pages 31038- 31040.
MS-DRG Validation for HIV
MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary’s medical record. Reviewers will validate claims where diagnosis code 042 Human Immunodeficiency Virus (HIV) disease was billed as secondary. Principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the claim will be reviewed for accuracy.
For guidance, see: ICD-9-CM Coding Manual (for dates of service on claim); ICD-9-CM Addendums and Coding Clinics; Medicare Program Integrity Manual chapter 6.5.3, section A-C DRG Validation Review, Uniform Hospital Discharge Data Set (UHDDS) – Reporting of Inpatient Data Elements, July 31, 1985; Federal Register (Vol. 50, No. 147), pages 31038- 31040.
CGI Federal
CGI, RAC for jurisdiction B (Ill., Ind., Ky., Mich., Minn., Ohio, Wis.), posted the following new issue pertaining to durable medical equipment (DME) on May 3:
Knee Orthoses
As defined in National Government Services’ Knee Orthoses Policy Article A47174, effective date July 1, 2008, revised Jan. 1, certain additions are considered not separately payable when billed with the related base code and will be denied as not separately payable.
Suggested resources:
Connolly Healthcare
Connolly Healthcare, RAC for jurisdiction C (Ala., Ariz., Colo., Fla., Ga., La., Miss., N.C., N.M., Okla., S.C., Tenn., Texas, Va., W.Va., Puerto Rico), most recently posted the following new issue pertaining to DME suppliers who bill CIGNA Government Services:
DME vs. Inpatient
DME claims should not be billed during an inpatient stay with the exception of: All L codes and codes that are within two days of discharge.
For additional information, see: Medicare Claims Processing Manual, chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); Medicare Claims Processing Manual, chapter 6 – SNF Inpatient Part A Billing and SNF Consolidated Billing; Medicare Claims Processing Manual, chapter 3 – Inpatient Hospital Billing; and Hospital Outpatient PPS Addendums A and B Updates.
Health Data Insights (HDI)
HDI, RAC for jurisdiction D, did not posted any new issues for May.
May 28th, 2010
Recovery Audit Contractors (RAC) HealthDataInsights (HDI) and CGI Federal have added to their list of new issues eligible for review as per the Centers for Medicare & Medicaid Services (CMS).
The RAC program, mandated by the Tax Relief and Health Care Act of 2006, is being implemented in 2010 to detect and correct past improper Medicare payments.
Tip: Don’t wait until Jan. 1, 2010 to review these new issues and correct any problems your outpatient hospital or physician practice may uncover. (more…)
November 2nd, 2009
Gearing up for the 2010 implementation of the Recovery Audit Contractor (RAC) program, HealthDataInsights (HDI) and Connolly Healthcare are the first to post issues eligible for review.
The RAC program, mandated by the Tax Relief and Health Care Act of 2006, is being implemented to detect and correct past improper payments so that the Centers for Medicare & Medicaid Services (CMS), claims processing contractors, and providers can take action to prevent future improper payments. (more…)
August 17th, 2009