As of August 26, 2009, the Recovery Audit Contractors (RAC) for Regions B, C, and D have posted the first issues for review.1 All of the initial issues for review are outpatient hospital or physician services. CGI Federal (Region B), Connolly Healthcare (Region C) and HealthDataInsights (Region D) have all identified the following issues for review:
-
Bronchoscopy Services (CPT Codes 36430, 36440, 36450, 36455, & 36460)
-
IV Hydration (CPT Code 90760 [10/1/07-12/31/08]; 96360 [1/1/09-present])
-
Blood Transfusions (CPT Codes 31625, 31628, 31629)
All three of these services should be billed as one unit per patient per date of service. In addition, Regions C and D have released the following common issues:
-
Untimed Codes: Regions C and D will look at codes that do not have a defined time frame (excluding those with Modifiers KX and 59) to ensure a unit of one was billed per date of service.
-
Once in a Lifetime Procedures: Regions C and D will review claims toensure beneficiaries are only provided certain procedures, like an appendectomy or an amputation, once in their lifetime.
-
Pediatric Codes Exceeding Age Parameters: Regions C and D will review claims to ensure that pediatric codes are not billed for beneficiaries who are too old to receive pediatric services.
-
Neulasta (Pegfilgrastim): CPT Code J2505 implies a dose of 6mg. Claims will be reviewed to ensure the units billed were listed in multiples of six rather than the total number of milligrams administered to the beneficiary.
Region C will also review Clinical Social Worker (CSW) Services for inpatients. CSW services during an inpatient stay are not separately payable by Medicare and are included in the hospital's DRG payment.2
With the publication of these issues, the RACs will begin the automated review process, and providers could start seeing RAC determination letters at any time. The automated review process is done through a data-mining of submitted claims and does not require providers to produce medical records upon a RAC request; those complex reviews likely will not begin until 2010.
In the meantime, providers should review timetables for responding to RAC determination letters, recoupment procedures, and timelines for filing RAC claims appeals. Many answers to commonly asked RAC questions may be found at http://www.hallrender.com/rac. Additionally, you may contact Joan Lowes jlowes@hallrender.com or 248-457-3857, Lori Wink lwink@hallrender.com or 414-721-0456, Liz Elias eelias@hallrender.com or 317-977-1468 or your regular Hall Render attorney.
1A map of the CMS RAC regions and implementation schedule is available at the following web site:
http://www.cms.hhs.gov/RAC/Downloads/RAC%20Expansion%20Schedule%20Web.pdf
2See the specific RAC websites for further guidelines:
Region B: http://racb.cgi.com/Issues.aspx?st=1
Region C: http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx
Region D: https://racinfo.healthdatainsights.com/Public/NewIssues.aspx
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm | 
