Aug 2009 – RAC Update

The following is from Lathrop Gage:

Connolly Healthcare, the Recovery Audit Contractor for Region C (which includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and the territories of Puerto Rico and U.S. Virgin Islands) has posted on its website the first CMS-approved audit issues. Unlike the RAC demonstration program, the permanent program requires a RAC obtain CMS approval before commencing audits addressing a specific issue. CMS has given the green light to Connolly to commence automated reviews for the following types of claims submitted by hospitals and physicians in South Carolina:

(1) Blood transfusions: CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one (1) per session, regardless of the number of units transfused on that date of service.

(2) Untimed codes: CPT Codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service.

(3) IV Hydration Therapy: Based on the definition of CPT 90760 (excluding claims modifier-59 ), the maximum number of units should be one per patient per date of service. Beginning 1.1.09, code 90760 was replaced with code 96360.

(4) Bronchosopy Services: CPT Codes 31625, 31628 and 31629 should be billed with a maximum number of units of one per patient per date of service (excluding claims with modifier 59) should only be reported with one unit per date of service.

(5) Once in a Lifetime Procedures: By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime.

(6) Pediatric Codes Exceeding Age Parameters: Newborn/Pediatric CPT codes being applied/billed for patients which exceed the age limit defined by the CPT code.

(7) J2505 (Injection, Pegfilgrastim, 6 mg): By definition HCPC Code J2505 represents 6 mg per unit. The code should be billed at one unit per patient per date of service.

For each, Connolly has identified resources available to providers concerning the subject, including CMS manual provisions, transmittals, and MLN Matters articles. More information is available at http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx. For now, these audits will be limited to hospitals and physicians in South Carolina. But there's every reason to believe CMS will approve the same automated reviews for the other RACs, and eventually all providers will be subject to these reviews. It's time for your RAC task force to review your practices in these areas and identify and correct any potential compliance issues.