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Recent RAC Updates

CGI Federal, RAC for Region B, added three new issues to its CMS-approved issues list for providers in all Region B states.

  • SNF consolidated billing. Services that are billed separately that should be included in the Skilled Nursing Facility Consolidated billing. Consolidated Billing is when services provided during the resident’s stay in a skilled nursing facility (SNF) are bundled into one package and billed by the Skilled Nursing Facility. Under the Consolidated Billing requirement, a Skilled Nursing Facility itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services).
  • DME while inpatient. The Medicare DMEPOS benefit is intended only for items that a beneficiary uses in his or her home. When a beneficiary is in a Part A inpatient stay, the institutional provider (e.g., hospital) is not defined as a beneficiary’s home for DMEPOS therefore; Medicare will not make separate payment for DMEPOS when a beneficiary is in the institution. The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay.
  • Multiple DME rentals billed per month. Medicare makes payments on a monthly basis for the rental of DMEPOS Fee Schedule items. The first claim’s billing date for the DMEPOS rental item is designated as the anniversary date. All subsequent billing must be dated monthly with the anniversary date. If a claim is submitted with a date that is earlier than the anniversary date and that DMEPOS item is not a replacement for a lost, stolen or irreparable damaged DMEPOS item, then the claim represents an overpayment.

HealthDataInsights, RAC for Region D, added five new issues to its CMS-approved issues list for providers in all Region D states. HealthDataInsights also added one new issue for providers in Alaska, Oregon and Washington.

  • Acute Inpatient Hospitalization – Traumatic stupor and coma, coma >1 Hr w/MCC (DRG 082). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Acute Inpatient Hospitalization Traumatic stupor and coma, coma >1 hr w/CC (DRG 083). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Acute Inpatient Hospitalization Traumatic stupor and coma, coma < 1 hr w/MCC (DRG 085). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Acute Inpatient Hospitalization Nontraumatic stupor and coma w/MCC (DRG 080). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Acute Inpatient Hospitalization Nontraumatic stupor and coma w/o MCC (DRG 081). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Mohs surgery with pathology billed by separate provider J2 (Alaska, Oregon and Washington only). If the preparation and interpretation of the slides of tissue taken during the Mohs surgery are performed by someone other than the surgeon or his or her employee, then mohs surgery may not be billed.

If you need assistance in preparing for, or defending against RAC audits, or implementing a compliance program geared toward identifying and correcting potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.