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Recent RAC Activity

DCS Healthcare, RAC for Region A, recently added four new issues for providers in Maryland and 16 new issues for providers in all Region A states to its CMS-approved issues list. Listed below are 6 examples of approved issues. Please visit DCS Healthcare’s website to view the remaining issues.

  • Musculoskeletal disorders MS-DRGs: 542-566. 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-DRG: 542-566 (Maryland)
  • Infections MS-DRG: 094-096;177-179;488-489;539-41;602-603;689-690;856-858;862-9;871-872;977. 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. (Maryland)
  • Renal and urinary tract disorders. 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. (Maryland)
  • Surgical cardiovascular procedures MS-DRGs: 246-254, 263-265. 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. (Maryland)
  • MS-DRG 081 nontraumatic stupor and coma without MCC. 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. (All region A)
  • MS-DRG 184 major chest trauma with CC. 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. (All region A)

Connolly Healthcare, RAC for Region C, recently added six new issues to its CMS-approved issues list.

  • Inappropriate billing of spring powered device (A4258). More than one spring powered device (A4258) per six months is not considered medically necessary.
  • Outpatient claims billed within a PPS inpatient admission. The reimbursement of outpatient services within a PPS hospital stay is considered a duplicate payment in the Medicare Claims Processing Manual. This reimbursement would be an overpayment for services that were previously processed and paid.
  • Inappropriate screening/diagnostic mammography payments. Local Coverage Determination policy has indicated specific conditions or diagnoses that are covered for screening (77057, G0202) and diagnostic (77051, 77055, 77056, G0204, G0206) mammography services. Outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies.
  • Multi-dose vial waste: Trastuzumab (Herceptin), J9355 outpatient hospital. Per its package label, Trastuzumab/Herceptin (J9355: INJECTION, TRASTUZUMAB, 10 MG) is supplied from the manufacturer in a 440mg multi-dose vial. Providers should only be billing units of J9355 associated with the amount of the drug administered to the patient. Drug waste is not paid and should not be billed for drugs supplied in multi-dose vials.
  • Bevacizumab – non-covered Dx. Local Coverage Determination policy has indicated specific conditions or diagnoses that are covered for Bevacizumab injections. Bevacizumab outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies.
  • Ambulance/transport services provided during an inpatient hospitalization. Ambulance transports provided by hospital-based ambulance suppliers to beneficiaries who are in an inpatient stay are the responsibility of the inpatient hospital provider with the exception of transports on the day of admission, day of discharge and during a leave of absence from the inpatient facility.

HealthDataInsights, RAC for Region D, recently added 25 new issues to its CMS-approved issues list. Listed below are three examples of approved issues. Please visit HealthDataInsight’s website to view the remaining issues.

  • Complications of treatment with CC (DRG 920). 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.
  • Poisoning and toxic effects of drugs with MCC (DRG 917). 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.
  • Traumatic injury with MCC (DRG 913). 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 defending against RAC audits or implementing a compliance program that will help identify and correct potential risk areas related to RAC audits, please contact a Wachler & Associates attorney at 248-544-0888.