Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 20, 2012 PDF

Plus: CMS clarifies 5010 advice.

When the Recovery Audit Contractor (RAC) system first began, providers stayed very well-connected to the review issues, but as time passed, some practices stopped paying attention. However, RACs continue to add new issues to their target lists, and it's incumbent upon you to keep track of the issues at hand.

For example: DCS Healthcare, the RAC for seven states in the Northeast, announced on Jan. 6 that it is reviewing overpayments made for E/M services billed without modifier 25 on the same date as allergy testing or allergen immunotherapy. "Claims having a 'claim paid date' which is more than three years prior to the ADR date will be excluded," DCS notes.

That same RAC has also been working to identify overpayments made by practices that billed more than one new patient E/M visit (such as 99201-99205) for the same patient within a three-year time period.

CGI Federal, the RAC which handles review for seven Midwestern states, has been identifying surgery claims reported by two physicians when one doctor appended modifier 62 (Co-surgery) and the other did not.

CGI is also reviewing add-on codes to find instances when MACs paid for add-on codes "when the required primary procedure either was not reported or was not paid for other reasons."

A third RAC (Connolly), which handles issues for 17 states, is currently reviewing global period billing following major surgeries when the claims don't include modifiers 58, 78, or 79.

Connolly is also reviewing claims that include a CPT code for chemotherapy administration but don't include the corresponding medication administered.

And the fourth RAC, HealthDataInsights (HDI), which covers 17 states and 4 U.S. territories, is looking at several additional issues. For instance, HDI is reviewing claims for outpatient E/M services (99201-99215) erroneously being billed for patients who are inpatients.

HDI is also looking at claims for services which appear to be rendered after a patient's date of death.