RACs: 5 Target Areas Your Group Need to Know

1. RACs: 5 Target Areas Your Group Needs to Know Jen Godreau, CPC, CPMA, CPEDC Director jenniferg@codinginstitute.com

2. Understand Alphabet Soup 2/24/2011 2

3. 2/24/2011 3

4. CMS Delays Medicaid RAC Program Source: CMS Bulletin 2/24/2011 4 “Out of consideration for state operational issues and to ensure states comply with the provisions of the final rule, we have determined that states will not be required to implement their RAC programs by the proposed implementation date of April 1, 2011.” When the Medicaid RAC Final Rule is issued later this year, it will indicate the new implementation deadline.

5. RAC Basics Purpose: Detect and correct past improper payments so CMS and the MACs can prevent such problems in the future. Employer: RACs are hired as contractors by the government, and they can collect “contingency fees”. Scope: The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007. Recovery: Between 2005 and 2008, RACs involved in the original demonstration project recovered over $1.03 billion in Medicare improper payments. 2/24/2011 5

6. RAC Fraud 2/24/2011 6 Referred only two cases of potential fraud to CMS “Because RACs do not receive their contingency fees for cases they refer that are determined to be fraud, there may be a disincentive for RACs to refer potential cases of fraud.” Source: OIG February Report

7. What Can You Do? Prevention Tips Know findings of OIG CERT Know findings of RAC Preliminary Program Know plan of RAC Implementation Program Know the target areas for your contractor Identify your weaknesses Review documentation before payments Review documentation postpayment Educate physicians, coders, billers 2/24/2011 7

8. RAC Preliminary Findings 2/24/2011 8 Source: RAC Error Report

9. RAC Preliminary Findings 2/24/2011 9 Source: RAC Error Report

10. Top Overpayments! 2/24/2011 10

11. IV Hydration Rule: Should be billed with a maximum number of units (1) per patient per date of service Setting: Outpatient Hospital, Physician Affected Areas: IL, IN, KY, MI, MN, OH, WI (MAC Region B), Connelly Consulting (MAC Region C) Codes: 90760 (deleted), 96360 (effective CPT® 2009) Descriptor: Hydration IV infusion , initial 2/24/2011 11 CPT© 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. All rights reserved.

12. Hydration: Initial Code = 1 Unit 2/24/2011 12 96360 (Intravenous infusion; initial, 31 minutes to 1 hour) Logic: Based on the hydration code’s definition, you should report this “initial” code once per patient per date of service Typically report 96360 only when medically necessary hydration is the lone infusion performed at the encounter. Exception: Can append modifier 59 (Distinct procedural service) for a legitimate reason Bottomline: Reporting 96360 more than once on a single date of service is highly unlikely.

13. 1 Unit Maximum Exception 2/24/2011 13 Can append modifier 59 if circumstances require that two separate IV sites be used Example: The IV in the left arm blows out or has complications after 31 minutes and another IV is started in the right arm that goes for 32 minutes. Code: 96360, 96360-59

16. Check that 31+ minutes to 60 minutes of hydration infusion is recorded for 96360; for intervals of greater than 30 minutes that go beyond one-hour increments, each additional hour is coded with 96361. No modifier is required.

17. Pull claims that contain a Chemotherapy and an IV hydration code. IV hydration may only be coded if documentation of start and stop times in the record that show the hydrations are given before or after chemotherapy.

18. Look at claims that contain a Therapeutic Infusion and an IV hydration code. Hydration may only be coded if the hydrations are given before or after the therapeutic infusion.

19. “Correct” claims that contain a IV hydration and blood transfusion code. IV hydration codes ARE NOT coded and/or reported with blood transfusion codes, regardless of when the IV hydration is administered.2/24/2011 15 Action Plan

21. 600cc infused with no start or stop times

22. medically unlikely amounts of medications versus route (for instance, “NS 400cc per hour flush”)

23. “Initial line (INT) removed/hep-lock discharged”

24. administration times that are marked through and/or illegible

26. remit any necessary refunds.“The RAC will be aware of the adjustment, but the refund does not preclude future review.” Source: RAC FAQs

28. Once in a lifetime procedures, which should be billed just once in a beneficiary’s lifetime.

29. Pediatric codes that are billed for patients who exceed the age limit defined by the CPT® code.2/24/2011 18 CPT© 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. All rights reserved.

30. 2/24/2011 19 Once in a Lifetime G0389 (Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm [AAA] screening) Code’s Purpose: Onetime AAA screening for Medicare patients referred following an initial preventive physical examination. Medicare coverage: The patient must meet one of the following risk categories: has a family history of AAA is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime is a beneficiary who manifests other specified risk factors.

32. Professional Component: Owner of the equipment bills the technical component with modifier TC (Technical component)

33. Problem: FIs and MAC A/Bs include TC component in hospital PPS payment.“Hospital bundling rules exclude payment of radiology services to suppliers of the TC portion of the radiology service for beneficiaries in a patients in a hospital inpatient stay.” 2/24/2011 20 CPT© 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. All rights reserved. Source: clm104c13

34. 2/24/2011 21 Split Billing Values 75310 (Radiologic examination, hip, unilateral; complete, minimum of 2 views) Payment Equation 26 + TC = Global Source: MPFS 2011 CPT© 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. All rights reserved.

36. Affected Regions: DCS Healthcare (Part A), Connolly Healthcare (Region C, SC only) Health Data Insights, Inc., (Region D, all 20 states in jurisdiction)

37. Type of Review: Automated

38. Settings: Outpatient & facility PT, OT, SLP

39. Rule: Enter only “one” in the units billed column per date of serviceRAC will not consider modifiers KX or 59 in these CPT® codes. 2/24/2011 22 CPT© 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. All rights reserved.

41. Solution: Alert billers to this potential snag.

42. Problem: Medicare allows you to use the 59 modifier to identify situations where you provided therapy to more than one body site. But you can’t use a modifier 59 for an untimed code.

43. Solution: Know your guidelines.CPT© 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. All rights reserved.

45. Do not need to appeal.Source: DCS Provider Notice, Feb. 16, 2011

47. Affected Areas: All

48. Setting: Physician, Outpatient

49. Type of Review: Automated

50. Guideline: Report 1 unit of Pegfilgrastim for per 6 mg injected

51. Old way: Prior to Jan. 1, 2004, Neulasta’s code descriptor (Q4053) indicated you should report one unit per 1 mg.

52. New way: The current definition requires one unit per 6 mg.2/24/2011 25 CPT© 2011 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. All rights reserved.

53. Resources AHANews, “CMS delays Medicaid RAC implementation.” Feb. 18, 2011. http://www.ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_021811_RAC&domain=AHANEWS Cheryl E. Servais, MPH, RHIA, “IV Hydration Documentation and Coding Could Be Vulnerable to RAC Audits Part 1.” RACMonitor.com. Aug. 12, 1009. http://racmonitor.com/news/12-from-the-editor/209-iv-hydration-documentation-and-coding-could-be-vulnerable-to-rac-audits-part-1.html CGI Federal, “IV-Hydration.” http://racb.cgi.com/IssueDetail.aspx?isd=2 CMS Bulletin, “CPI-B-11-03.” Feb. 1, 2011. https://www.cms.gov/MedicaidIntegrityProgram/Downloads/6411racdelay.pdf CMS, Medical Claims Processing Manual, Chapter 13. http://www.cms.gov/manuals/downloads/clm104c13.pdf CMS Manual System, “Pub 100-04 Medicare Claims Processing.” Nov. 17, 2006. http://www.cms.gov/transmittals/downloads/R1113CP.pdf CMS, “MLNMattersArticles SE1028.” https://www.cms.gov/MLNMattersArticles/downloads/SE1028.pdf CMS, “RAC Evaluation Report.” http://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf 2/24/2011 26

54. Resources CMS RAC Web site www.cms.hhs.gov/RAC/Downloads/RAC%20Expansion%20Schedule%20Web.pdf DCS Healthcare. “Important Provider Notice: February 16, 2011.” http://www.dcsrac.com/PROVIDERPORTAL.aspx Deborah Dorton, JD, MA, CPC, CHONC, “Focus on Transfusion, Hydration, and J2505 — Before RACs Do.” Oncology and Hematology Coding Alert. October 2009. http://www.supercoder.com/articles/articles-alerts/onc/focus-on-transfusion-hydration-and-j2505-before-racs-do/?zoom_highlight=96360+racs Deborah Dorton, JD, MA, CPC, CHONC, “Red Flag: G0389 May Be a Potential RAC Target.” Oncology and Hematology Coding Alert. September 2009. http://www.supercoder.com/articles/articles-alerts/rca/red-flag-g0389-may-be-a-potential-rac-target/?zoom_highlight=radiology+rac Federal Register, Proposed Rules. “Medicaid Program; Recovery Audit Contractors.” Nov. 10, 2010. http://edocket.access.gpo.gov/2010/pdf/2010-28390.pdf OIG, “Review of Medicare Part B Claims for Neulasta – Wisconsin Physicians Service for the Calendar Years 2004 Through 2007.” June 2009. http://www.oig.hhs.gov/oas/reports/region5/50900070.pdf 2/24/2011 27

55. Resources Jan Milliman, MA, HCS-D, COS-C, “NEWS BRIEFS: Careful — RACs Are Watching Your Untimed Therapy Codes.” Physical Medicine & Rehabilitation. September 2009. http://www.supercoder.com/articles/articles-alerts/pmc/news-briefs-careful-racs-are-watching-your-untimed-therapy-codes/?zoom_highlight=physical+therapy+rac Jan Milliman, MA, HCS-D, COS-C, “Billing: Make Time to Target Untimed Codes on Your Part B Therapy Claims.” Physical Medicine & Rehabilitation. April 2010. http://www.supercoder.com/articles/articles-alerts/pmc/billing-make-time-to-target-untimed-codes-on-your-part-b-therapy-claims/?zoom_highlight=physical+therapy+rac Torrey Kim, MA, CPC, CGSC, “In other news...” Part B Insider. June 2010. http://www.supercoder.com/articles/articles-alerts/pbi/in-other-news...-102017/?zoom_highlight=neulasta Torrey Kim, MA, CPC, CGSC, “In other news...” Part B Insider. September 2010. http://www.supercoder.com/articles/articles-alerts/pbi/in-other-news...-102988/?zoom_highlight=physical+therapy+rac Torrey Kim, MA, CPC, CGSC, “RAC AUDITS: RAC Contractors List 7 Audit Issues on Their Radar Screens.” Part B Insider. August 2009. http://www.supercoder.com/articles/articles-alerts/pbi/rac-audits-rac-contractors-list-7-audit-issues-on-their-radar-screens/?zoom_highlight=96360+racs 2/24/2011 28

56. Resources ZPIC Information http://www.cms.gov/manuals/downloads/pim83c04.pdf 2/24/2011 29

57. 2/24/2011 30 RAC Sites

58. Thank you for attending today’s Webinar. Post questions to SuperCoder.com/Forum 2/24/2011 31

59. 2/24/2011 32 Coming in March … HCPCS 2011 Changes Register at SuperCoder.com/conference/