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The following article is written by Cristina Bentin, CCS-P, CPC-H, CMA, president of Coding Compliance Management.
Ambulatory surgery centers continue to receive RAC informational letters with a "Splain Yourself, Lucy" directive.
The most recent issues include:
1. Lack of medical necessity
Target: Pain management cases. When reviewing the R/A for certain pain management cases, no fluoroscopy was indicated/reported on the claim. Keep in mind, several types of pain management injections warrant the utilization of fluoroscopy to perform the procedure. However, certain CPT codes are inclusive of fluoroscopy within its verbiage; thus, separating reporting for the fluoroscopy would be incorrect coding/billing. On the flip side, those pain injection CPT codes that don't include fluoroscopy within its verbiage may not reflect the additional fluoroscopy CPT code on the R/A for Medicare accounts. This is due to Medicare reporting policies for HCPCS (such as the fluoroscopy code 77003, for example) listed as a packaged service/packaged reimbursement (N1 indicator).
Facilities are providing the RACs with the actual operative reports reflecting the utilization of fluoroscopy as well as fluoroscopic photos as evidence. When applicable, ASCs are providing the Medicare Claims Processing Manual Chapter 14 –ASC billing guidelines that state, "ASCs should not report separate line-item HCPCS codes or charges for items that are packaged into payment for covered surgical procedures and therefore, are not paid separately". These guidelines go on to say, "Facilities may not be paid appropriately if they unbundle charges and report those charges for packaged codes as separate line-item charges." As a result, RAC take-backs are being prevented/dismissed.
In regards to other related RAC information request letters in which medical necessity for injections has been challenged, after further review of the accounts, the actual coding for the pain injections was incorrect. The reimbursement impact is lower than what was due to the ASC. While fluoroscopy is easily proven, the RACs are still in the process of reviewing the ASC responses regarding underpayments.
Here's an opportunity for all ASCs to ensure its coders and payment posters understand the reimbursements due to their facility. Don't settle for "any" reimbursement. Expect the correct reimbursement.
2. Duplicate billing
Target: Cataract cases. In accordance with a RAC review, duplicate billing has been a target by RACs particularly in the performance of cataract surgeries. A few facilities have reported erroneous billing due to the incorrect application of laterality modifiers (left versus right). Did the coder err when reporting the procedure or did the surgeon err when dictating the procedure description? In this case, the challenge has been from a surgeon perspective with the incorrect laterality modifier documented on the operative report. While both eyes have been surgically corrected, the surgeon documented the same eye on both operative reports. Many errors were due to the utilization of "template-type" operative report formats which is an open forum for errors to occur. ASCs were able to provide backup regarding work performed on contralateral eyes to prevent a take-back. Appropriate protocols were implemented to prevent a duplication of errors, templates were discontinued, corrected claims were submitted per the RAC to the RAC and take-backs were prevented/questions dismissed.
What to do
ASCs should be diligent in responding to its RAC. Don't let RAC correspondence get lost in the shuffle. Educate your facility mail handlers on the "appearance" of RAC correspondence, letterheads and logos. Many RAC letters have been lost in the paper shuffle of your business office as simply another denial letter. ASC facilities can go online and review many form letters from its respective RACs.
To contact Cristina Bentin (cristina@ccmpro.com) and learn more about Coding Compliance Management, visit www.ccmpro.com.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
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