RACs Add to Lengthy CMS-Approved Issues

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  • In CMS
  • January 27, 2010
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There’s certainly no grass growing under the feet of the Centers for Medicare & Medicaid Services’ (CMS’) four appointed Recovery Audit Contractors (RACs). Each company has been hard at work posting new CMS-approved issues for review. Whereas RACs’ initial focus seemed to be on outpatient services, the target now also seems to be on inpatient services.

DCS Healthcare – Region A

DCS Healthcare’s first post for 2010 pertains to unbundled ambulance services during an inpatient hospital stay. This issue, posted Jan. 7,  is for automated review of overpayments. DCS also added three new Medicare Severity-Diagnosis Related Group (MS-DRG) validation issues on Jan. 19 of this year (although the postings are dated for last year).
At this time, medical necessity is excluded from review for the following three new MS-DRG validation issues:

  • MS-DRGs with Ventilator Support of 96+ Hours
  • MS-DRG 189 Pulmonary Edema & Respiratory Failure
  • MS-DRGs for Tracheostomy

You can view all of the CMS-approved issues for review in Region A (District of Columbia, Connecticut, Maine, Massachussetts, Delaware, New Jersey, New York, New Hampshire, Pennsylvania, Rhode Island, and Vermont) posted on the DCS Healthcare website.

CGI Federal – Region B

CGI Federal removed medically unlikely edits (MUEs) it had posted in 2009 and posted 19 new issues for non-medical necessity MS-DRG validation inpatient claims on Jan. 11. This is in addition to the 17 MS-DRG validation issues the RAC posted in December 2009.
The latest MS-DRG validation issues for inpatient claims at press time are as follows:

  • Acute Respiratory Failure
  • Cardiac Defib Implant w/ Cardiac Cath w/o AMI/HF/Shock w/MCC
  • Cardiac Valve & other Major Cardiothoracic Procedures w/CC or MCC
  • Carotid Artery Stent & Extracranial Procedures w/ CC or MCC
  • Coronary Bypass w/PTCA/Cardiac Cath w/MCC
  • Cranial/Facial Procedures w/CC or MCC
  • Craniotomy, Endovascular and Intracranial Vascular Procedures w/CC or MCC
  • Disorders of the Eye, Infectious and Procedures (Orbital and Interocular) w/CC or MCC
  • Major Cardiovascular Thoracic Aortic Aneurysm Repair Procedures w/CC or MCC
  • Major Chest Procedures w/CC or MCC
  • Major Head & Neck Procedures w/CC or MCC
  • Other Cardiothoracic Procedures w/CC or MCC
  • Other Ear, Nose, Mouth & Throat OR Procedures w/CC or MCC
  • Perc Cardiovasc Proc w/Drug-Eluting or Non-Drug-Eluting Stent w/MCC or 4+ Vessels/Stents
  • Periph/Cranial Nerve and Other Nerv Syst Procedures w/CC or MCC
  • Spinal Procedures Neurostimulators w/CC or MCC
  • Tracheostomy Overpayment
  • Tracheostomy Underpayment
  • Ventricular Shunt Procedures w/ CC or MCC

On Jan. 5, CGI also added to its CMS-approved list a new issue for clinical social work (CSW) during an inpatient hospital stay.
Complete descriptions and policy-related links for all of CGI’s approved issues are available on the company website.

Connolly Healthcare – Region C

There were no new issues to report at press time. No doubt, this RAC is still recovering after posting more than 40 new issues in December 2009.

HealthDataInsights – Region D

HealthDataInsights (HDI) also is apparently taking a breather after posting several MS-DRG validation issues for review in December 2009. The company has posted just one new issue so far this year.
Medical Supplies and Home Health Consolidated Billing applies to claims paid on or after Oct. 1, 2007 under the Prospective Payment System (PPS).
As with the other RACs, you can view all of HDI’s CMS-approved issues online.

Certified Inpatient Coder CIC

No Responses to “RACs Add to Lengthy CMS-Approved Issues”

  1. Karen Wolmer says:

    Ok, so the RAC is making some progress. Great, however all issues reported to OIG still fall on deaf ears. They are recovering monies, but maybe someone will go after the actual physicians committing fraud. There are several physicians out there still lining their pockets from their self referrals to their own ASC’s. Taking monies illegally from the NIH, billing incorrectly, over utilization, where is RAC and the OIG on these issues. I’ve come to realize that the State Attorney General and the US Department of Justice could care less about pursing physicians, they want the big money to make themselves a name. It make’s me proud to be an American.