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Recent RAC Updates (DCS Healthcare and CGI Federal)

DCS Healthcare, the RAC for Region A, posted four new issues to its CMS-approved issues list for providers in Maryland.

  • Medical Necessity Review (MNR)- MDC 5 conditions of the circulatory system (medical) MS-DRGs: 286-293, 299-305, and 308- 316. 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. MS-DRGs: 286-293, 299-305, and 308- 316.
  • Medical necessity: acute inpatient admission neurological disorders MS-DRG’s: 068-074, 103, 312 (Collaborative). RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRG’s, 068-074, 103, and 312.
  • Medical necessity: acute inpatient admission respiratory conditions (collaborative) the MS DRGs affected are MS DRG 177-180, MS DRG 190-198 and MS DRG 202-206. RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly. The MS DRGs affected are MS DRG 177-180, MS DRG 190-198 and MS DRG 202-206.
  • Medical necessity review (MNR)- MDC 6 diseases and disorders of the digestive system MS-DRGs: 347-358, 368-395. 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. MS-DRGs: 177-180, MS DRG 190-198 and MS DRG 202-206.

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

  • Verteporfin and ocular photodynamic therapy without fluorescein angiography. The purpose of this audit is to identify overpayments associated with providers billing for Verteporfin (J3396) and Ocular Photodynamic Therapy (OPT) (67221-67225) in the absence of fluorescein angiography (92235) or indocyanine-green angiography (92240) performed prior to each treatment.
  • Multiple dose allergy vials. The purpose of this complex review is to ensure accurate reporting of CPT code 95165 (preparation and provision of antigens for allergen immunotherapy).
  • Excessive billing of positive airway pressure (PAP) and respiratory assist device (RAD) accessories. Medicare allows payment of PAP and RAD accessories when coverage criteria for the devices have been met. However, the National Government Services Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L27230) state that when supplies are dispensed more frequently or in quantities of supplies greater than usual maximum amounts are dispensed, they will be denied as not medically reasonable and necessary.
  • Leuprolide 3.75mg incorrect code reported – outpatient. 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(s) bills for greater than 3 units of service for HCPCS code J1950, as defined by applicable Local Coverage Determination documents.

Connolly Healthcare, RAC for region C, has added 33 new issues to its CMS-approved issues list. Listed below are the approved issues for inpatient hospital claims. Please visit Connolly’s website to view the remaining issues.

  • Acute readmission – No B4. Same day readmission to the same facility for similar/same symptoms should be considered as 1 stay and hospital should adjust to make the entire stay on one claim only.
  • Post-acute transfer – underpayments. Inpatient claims were identified with discharge disposition to an acute care inpatient facility (02), skilled nursing facility (03), home health (06), Inpatient rehab facility (62), long-term care facility (63), or psychiatric facility (65). These inpatient claims fall under the Post Acute Transfer policy and are reimbursed on per diem rate, up to full MS-DRG reimbursement. However, there is no identified claim submission from a receiving facility.

HealthDataInsights, RAC for region D, has added 36 new issues to its CMS-approved issues list for providers in all region D states. Listed below are two examples of approved issues for short-term acute care hospitals. Please visit HealthDataInsights’ website to view the remaining issues.

  • Acute Inpatient Hospitalization – Coronary Bypass without Cardiac Cath without MCC (DRG 236). 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 – Viral Meningitis without CC/MCC (DRG 076). 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.

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.