Are Recovery Auditors Reviewing Your Claims?

Are Recovery Auditors Reviewing Your Claims?

Recovery Auditors have been busy. This year alone there are 23 topics under review and three more were just proposed. If you are coding/billing for any of the topics under review, this may be all the reason you need to conduct an internal review.

Who Are They?

Recovery Auditors, or Recover Audit Contractors (RACs), review claims on a post-payment basis for the purposes of detecting and correcting past improper payments. The Centers for Medicare & Medicaid Services (CMS) and contracted payers then implement actions that will prevent future improper payments.

Current RACs are:

Region 1 – Performant Recovery, Inc. (CT, IN, KY, MA, ME, MI, NH, NY, OH, RI, VT)

Region 2 – Cotiviti, LLC (AR, CO, IA, IL, KS, LA, MO, MN, MS, NE, NM, OK, TX, WI)

Region 3 – Cotiviti, LLC (AL, FL, GA, NC, SC, TN, VA, WB, Puerto Rico, US Virgin Islands)

Region 4 – HMS Federal Solutions (AK, AZ, CA, DC, DE, HI, ID, MD, MT, ND, NJ, NV, OR, PA, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas)

Region 5 – DME/HHH/Performant Recovery, Inc. (Nationwide)

Region 1-4 RACs perform post-payment reviews on Medicare Parts A/B claims and the Region 5 RAC reviews Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and home health/hospice (HHH) claims.

Current Topics Under Review

Table A lists all the topics for review beginning in 2019. Details of these reviews are available on the CMS’ Medicare Fee for Service Recovery Audit Program website. The details provide clues for what to look for.

For example, details for HCPCS A4253: Blood Glucose Test or Regent Strips tells us that Recovery Auditors initiated complex reviews of claims submitted by DME suppliers and providers in all states beginning March 5. Documentation will be reviewed to determine if the utilization guidelines for blood glucose test strips (A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips) were met. Here’s the clue: “The quantity of glucose test strips that are covered depends on the usual medical needs of the diabetic patient.” Meaning, they’re looking at documentation to support the units billed.

A list of references to applicable policies is also given (although, unfortunately, not hyperlinked). Best practice is to go to the payer’s website and look up their policy for A4253.

For example, Noridian Medicare’s Local Coverage Determination L33882 tells us that the quantity of test strips covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having type 1 or type 2 diabetes mellitus. The LCD includes complete coverage guidelines of these testing supplies.

Table A: Approved RAC reviews initiated in 2019

Name Review Type Claim Type Region
Medical Necessity Pannulectomy Complex Outpatient Hospital, ASC, Professional A/B MACs
Pneumatic Compression Device Complex DME Suppliers/Providers DME MACs A-D
E/M Save Day as Admission to a Nursing Facility Automated Physician/NPP A/B MACs
PET Scans Paid without Tracer Codes Automated Independent Diagnostic Testing Facility A/B MACs
Cryosurgery of the Prostate Complex Outpatient Hospital, ASC, Professional A/B MACs
Cardiac Rehabilitation Complex Outpatient Hospital A/B MACs
Complex Chest X-ray Complex Outpatient Hospital, Professional JE, JF
IV Hydration Administration Complex Outpatient Hospital JE
SNF-Consolidated Billing for Therapies Automated Physician/NPP, PT, OT, SLP All States
Complex Medical Necessity Vertebroplasty and Kyphoplasty Complex Outpatient Hospital, ASC, Professional A/B MACs
Pulmonary Rehab Complex Outpatient Hospital All States
Therapeutic Shoes and Inserts for Persons with Diabetes Complex ASC, SNF DME MACs A-D
ASC Services During a Covered Part a SNF Stay Automated ASC, SNF All States
Medical Necessity for Vitamin Assay D Testing Complex Laboratory Service JE/JF
Off-the-shelf Knee Orthosis Complex DME Supplier/Provider All DME MACs
Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins Complex ASC, Outpatient Hospital, Professional A/B MACs
Unbundling of CT Scans Automated Outpatient, Professional All States
Unbundling of MRI Procedures Automated Outpatient, Professional All States
Knee Orthosis within the RUL Automated DME Supplier/Provider All DME MACs
Subsequent Hospital Visit and Discharge Day Management Billed on Same Day Automated Professional All Regions
Mohs Micrographic Surgery: Units Billed Complex Professional All Regions
Physician/NPP Coding Validation Complex Professional All Regions
HCPCS A4253: Blood Glucose Test or Reagent Strips Complex DME Supplier/Provider All DME MACs

Proposed Topics for Review

Recovery Auditors also propose to conduct complex reviews for the topics shown in Table B.

Table B: Proposed topics for review

Name Review Type Claim Type Region
ASC Coding Validation Complex ASC All Regions
Medical Necessity for ALS and BLS Non-emergency Ambulance Services Complex Laboratory, Ambulance All Regions
Upper Limb Orthosis within the RUL Automated DME Supplier/Provider All DME MACs

 

Take a proactive approach: Audit claims for improper payments and correct coding and documentation discrepancies for optimal revenue cycle management.


Source:

Certified Professional Medical Auditor

CMS, Medicare Fee for Service Recovery Audit Program

Renee Dustman
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Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman
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About Has 662 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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