Knowledge Base Article

It has been a while since we have reviewed the issues approved for audit by the Recovery Auditors (RACs). Since CMS has banned the review of the medical necessity of inpatient admissions by RACs (other than upon referral from the QIO), the impact of RAC reviews is greatly diminished from their prior Statement of Work. This does not mean they have been idle. Currently, there are 105 CMS approved RAC Topics across all types of providers. Between the RAC reviews and reviews by the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) reviewers, and other Medicare entities, providers may still feel overwhelmed by the enormity of the task of ensuring appropriate billing, accurate coding, and complete documentation for Medicare services. When you are overwhelmed, we all know that you have to eat that elephant one bite at a time.

You can see a listing of the approved topics and proposed review topics on CMS’s Recovery Audit Program website. The website also includes links to the websites of the various Recovery Auditors where you can find your specific state RAC’s active review topics. Hospital inpatient and outpatient review topics approved by CMS since the beginning of this year are discussed below. Topic posting dates and claim types may vary from RAC to RAC so providers need to review their RAC’s website to see if the claim type is applicable to them. As a reminder, automated reviews can result in automatic denials based solely on claims data. The RAC will request medical record documentation from the provider for complex reviews and coverage/payment decisions are based on that documentation.

0074 - Excessive or Insufficient Drugs and Biologicals Units Billed (complex review)

Drug and biological units should be reported in multiples of the dosage specified in the HCPCS code long descriptor. Units are determined by dividing the amount of the drug administered by the dosage in the HCPCS descriptor. If there is drug wastage that meets Medicare requirements for billing and is appropriately documented, it can also be billed with the JW modifier and units determined the same as for the administered drug. If the amount of drug used is not a multiple of the HCPCS code dosage descriptor, round up to the next highest unit. Claims will be reviewed to determine the actual amount administered and the correct number of billable/payable units. (Affected Codes - 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)

0078 - Complex Cardiac Pacemaker Review (complex review)

Medicare coverage for pacemakers is defined in National Coverage Determination NCD 20.8.3 and in numerous Medicare Administrative Contractor (MAC) coverage articles (e.g. Palmetto's Cardiac Pacemaker Coverage Article). Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. (Affected Codes - 33206, 33207, 33208)

0083 - Cataract Removal Excessive Units (Partial)

0084 - Cataract Removal Excessive Units (Full) (automated reviews)

Medicare will only pay for one cataract removal performed on the same eye on the same date of service. Claims with more than one unit of cataract removal for the same eye, on the same claim line, will be partially denied and payment will only be made for one cataract removal. This may be the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”

If there are multiple claims for cataract removal for the same patient for the same eye, only one will be paid and the others fully denied. (Affected Codes - CPT 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984)

0085 - Lab Services Rendered During an Inpatient Stay (automated review)

Laboratory services provided to a patient during an inpatient admission are paid as part of the DRG payments and are not separately billable to Medicare. These services should be denied as unbundled services. (Affected Codes - 80048-80076, 80150-80203, 80400-80439, 81000- 81050, 82009-84830, 85002- 85810, 86602- 86804, 87003-87905)

0092 - Percutaneous Implantation of Neurostimulator Electrode Array (complex review)

NCD 160.7.1 describes Medicare coverage of percutaneous electrical nerve stimulation. Documentation in the medical record must support the code billed was actually the service rendered and that all coverage criteria were met. (Affected Codes - 64553, 64555)

0093 - Automatic Defibrillators (complex review)

Medicare has a long and complex NCD (NCD 20.4) for implantable automatic defibrillators, electronic devices designed to detect and treat life-threatening tachyarrhythmias. Prior reviews by the Department of Justice (DOJ) and other Medicare entities have found numerous claims billed that did not meet Medicare requirements. The RACs will be reviewing documentation to support medical necessity and validate that implantable automatic cardiac defibrillators are used only for covered indications. (Note: there is a pending update to this NCD that should be finalized soon.) (Affected Codes - 33240, 33241, 33242, 33243, 33249)

0095-Facet Injections (complex review)

Facet Joint Injections are reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Medical documentation will be reviewed to determine that services were medically reasonable and necessary. Although this issue has been approved by CMS, so far none of the RACs have added this to their approved issues list. (Affected Codes - 64490-64495, 64633-64636, 0213T-0218T, G0260)

0099-Skilled Nursing Facility (SNF) Consolidated Billing (automated review)

Most services provided to a Skilled Nursing Facility (SNF) inpatient (skilled stay) are part of the SNF consolidated billing prospective payment. This means the Medicare Part A payment made to the SNF includes payment for these services. Other outpatient providers that furnish these services to a SNF inpatient must receive payment from the SNF. A few select services are exempt from consolidated billing and the rendering provider can bill Medicare directly for these exempt services. Refer to the Medicare SNF Consolidated Billing website for information and lists of exempt categories and codes. (Affected Codes - CPT/HCPCS codes listed in the SNF Consolidated Billing Table, Major Category I.F and V.A.)

0101-Outpatient Hospital Comprehensive APC Coding (complex review)

For comprehensive APCs, Medicare makes one inclusive payment for the primary procedure and all adjunctive services. This means payment for most services is not made separately but bundled into the payment for the primary service. If the primary service is not billed properly or not supported by documentation, the entire claim may be denied. According to CMS’s explanation of the issue, “Comprehensive APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.” (Affected Codes – Codes with an OPPS status indicator (SI) = J1)

The good news about the RAC issues under the current scope of work is that the limited number of issues makes it easier for providers to internally review their processes and documentation to ensure they are meeting Medicare requirements. It is also easier to make improvements if deficiencies are found and limit future recoupments. Providers may still feel like they are eating an elephant one bite at a time, but at least the bites are smaller.