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Recent RAC Updates (CGI Federal New Issues and CIGNA Government Services New Issues)

CGI Federal, the RAC for Region B, added two new issues to its CMS-approved issues list. In addition, two more issues were added to the CMS-approved issues list for DME suppliers who bill CIGNA Government Services.

CGI Federal New Issues

  • Leuprolide 3.75mg incorrect code reported (Region B). The purpose of the complex review is to identify the incorrect use of HCPCS code and corresponding number of units billed for services of Leuprolide (depot suspension) 3.75mg. An overpayment exists when a provider bills for greater than 3 units of service for HCPCS code J1950, as defined by applicable Local Coverage Determination documents.
  • Pharmacy supply dispensing fee (Region B). Medicare pays pharmacy supply/dispensing fees for immunosuppressive, oral anti-cancer, chemotherapeutic, and oral anti-emetic drugs as well as drugs used as part of an anti-cancer chemotherapeutic regimen when they are submitted on the same claim as the drug being billed. A claim submitted with a pharmacy supply/dispensing fee in the absence of any of the previously mentioned drugs represents an overpayment and will be denied as not medically reasonable and necessary.

CIGNA Government Services New Issues

  • Osteogenesis stimulators (DME suppliers who bill CIGNA Government Services). An overpayment exists when a provider bills for an osteogenesis stimulator with an ICD-9 code that is not included in the list of covered ICD-9 codes within the applicable Local Coverage Determination documents.
  • Overuse of PAP/RAD accessories (DME suppliers who bill CIGNA Government Services). A supplier must not dispense more than a certain quantity of PAP/RAD accessories at a time. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary.

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.