Recent RAC Updates

DCS Healthcare, RAC for Region A, added two new issues subject to medical necessity reviews to its CMS-approved issues list for providers in Maryland. DCS Healthcare also added four new issues for providers in all Region A states.

• MS-DRG 286, 287 Cardiac Catheterization for Ischemic Heart Disease (All severity and risk of mortality levels) (Maryland only). 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. This review will be of MS-DRG 286, 287 cardiac catheterization for ischemic heart disease.
• MS-DRG 149 vertigo and other labyrinth disorders (All severity and risk of mortality levels) (Maryland only). 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. This review will be of MS-DRG 149 vertigo and other labyrinth disorders.
• National correct coding initiative (CCI) – Part B (All Region A states). Application of the Part B National Correct Coding Initiative (Mutually exclusive and non-mutually exclusive). Deny Column II code when billed by the same provider and same date of service as a Column I code.
• New patient visits (All Region A states). Identification of overpayments relating to the same provider group and specialty billing more than on new patient Evaluation and Management services within a 3 year period of time.
• Add-on codes paid without a paid required primary procedure (All Region A states). Claims overpaid for add-on codes when the required primary procedure is not billed by the same provider on any claim (same or different) for the same date of service.
• Global surgery – Pre and post-operative visits (All Region A states). Identification of overpayments associated to minor and major surgical services.
  1. E/M services (as specifically defined in the IOM) billed the day prior to a major (90-day) surgical service without modifiers 57 or 25.
  2. E/M services (as specifically defined in the IOM) billed the day of a major (90-day) or minor (0- or 10-day) surgical service billed without modifier 25 or 57.
  3. E/M services (as specifically defined in the IOM) billed 10 days following a 10-day minor surgical service or 90 days following a 90-day major surgical service and billed without modifier 24 (unrelated visit in post op period). 

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.