RACs Post New Issues Under Review

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 BillingMedicare 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.

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