The following article is written by Cristina Bentin, CCS-P, CPC-H, CMA, president of Coding Compliance Management.
RACs are stepping up the pace in terms of ambulatory surgery center automated claims reviews.
Top issue as reported by several ASCs: Post-operative period/global period.
Recently, many ASCs are getting demand letters based upon the RAC's erroneous application of physician reporting/billing guidelines rather than the application of ASC facility reporting/billing guidelines resulting in recoupment requests (misconception of duplicate claims or incorrect modifier usage during the global period).
As a proactive measure and to strengthen the ASC facility's reporting/rebuttal position, CMS was asked to clarify an ASC's 24 hour post-operative period. According to CMS, April 5, 2011, "ASC surgeries are same-day surgeries and do not include the "global period" concept. The global period refers to physician services. The term physicians' services includes any routine pre- or post- operative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services which the individual physician usually includes in the fee for a given surgical procedure. The ASC procedure facility payment also includes the post-operative recovery or convalescent time in the facility."
Facilities should not accept any demand/recoupment letter as "law" with a "refund now and fight later" mentality. Facilities must review, research and rebut. A facility that never appeals or rebuts any audit when warranted could find itself under the microscope more frequently than it would prefer. If your facility isn't taking the time to provide documentation to support its position for each account found to be incorrect, why would RAC close the window of opportunity for future recoupment?
Don't become an ongoing target. Develop a strategy for appealing unfavorable RAC determinations. Remember, during the RAC demo, many appeals were won by providing current and credible documentation, (i.e. Local Coverage Determinations, CMS guidelines etc.) Facilities need to respond quickly should they receive a notice of an impending recoupment.
Editor's note: Read more about RACs from Ms. Bentin in the column "Guide to Understanding RACs: 5 Steps for Your ASC to Become Better Prepared."
To contact Cristina Bentin (cristina@ccmpro.com) and learn more about Coding Compliance Management, visit www.ccmpro.com.
Read more from Cristina Bentin:
- 2011 Coding Changes to Nervous System
- 2011 Coding Changes to Eye and Ocular Adnexa