CMS Posts Proposed Review Topics for Recovery Auditors

on Thursday, 16 November 2017. All News Items | Recovery Auditor

November Review Topics Posted November 13, 2017

As we approach the holiday season, I can’t help but be reminded of the hurdle that students face before enjoying the holiday break, final exams. Preparing for exams can definitely be a challenge. However, as a senior in high school, my Western Civilization History teacher gave us a heads up as to what we could expect. She provided the class with five topics and the entire final exam was to be able to write a five paragraph essay about just one of the five proposed topics. While still daunting, at least we knew what was coming.

It seems CMS has followed suit when it comes to the Recovery Audit Program. On November 13th CMS announced that they have begun “to post a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis” on the CMS Recovery Audit Program Provider Resources web page.

Review Topics being proposed for November

  • Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary,
  • Respiratory Assistive Devices: Meeting Requirements to be considered Reasonable and Necessary,
  • Excessive or Insufficient Drugs and Biologicals Units Billed,
  • E&M Codes billed within a Procedure Code with a “0” Day Global Period (Endoscopies or some minor surgical procedures),
  • E&M Codes billed within a Procedure Code with a “10” Day Global Period (Other minor procedures); and
  • E&M Codes billed within a Procedure Code with a “90” Day Global Period (major surgeries).

CMS provides a description, the state(s)/MAC regions where the reviews will occur, the review type, the Provider type, affected code(s) when applicable, and applicable policy references for each review topic. As MMP works closely with IPPS hospitals, let’s take a closer look at the details provided by CMS for a review topic for the Outpatient Hospital.

Review Topic: Excessive or Insufficient Drugs & Biologicals Units Billed
Description Drugs and biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate, discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Claims billed with excessive or insufficient units will be reviewed by a nurse, registered pharmacist, certified pharmacy technician, or certified coder to determine the actual amount administered and the correct number of billable/payable units.
State(s)/MAC Regions where reviews will occur All states
Review Type Complex Review
Provider Type Outpatient Hospital & Physician
Affected code(s) C9025, C9295, J0129, J0178, J0256, J0583, J0585, J0894, J0897, J1300, J1459, J1561, J1566, J1569, J1572, J1745, J2323, J2353, J2357, J2505, J2778, J2796, J2997, J3101, J3262, J3487, J7325, J9033, J9035, J9041, J9043, J9055, J9171, J9228, J9263, J9264, J9299, J9303, J9305, J9306, J9310, J9351, J9355, Q2050, J9034, J9310
Applicable Policy References · Social Security Act, Section 1833. [42 U.S.C. 1395l] (e)
· 42 CFR §405.980 (b) and (c)
· 42 CFR §405.986
· CMS IOM 100-04, Chapter 17, Sections 10, 40, 70 and 90.2

Similar to my history teacher, by posting proposed Review Topics, CMS is giving you a heads up as to what is coming. Hospitals should take this opportunity to validate compliance within your own facility.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.  In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare.  You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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