DCS Healthcare, the recovery audit contractor for Region A, posted the following CMS-approved audit issues on February 9-11.
1. MS-DRG validation for joint procedures. MS-DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded on the hospital claim, matches both the attending physician description and the information contained in the medical record. This review includes MS-DRGs 461, 480, 482, 483, 484, 485, 487, 489, 492, 493, 494, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514, 535, 536, and 906.
2. Back and neck procedures except spinal fusion. This medical necessity review is for MS-DRG 491, back and neck procedures except spinal fusion without CC/MCC. 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.
3. MS-DRG validation for cervical spinal fusion. This involves medical necessity review of MS DRG 473, cervical spinal fusion without cc/mcc.
4. Extracranial procedures without CC/MCC. This involves determining the medical necessity of an inpatient setting for MS DRG 039, extracranial procedures without CC/MCC. 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.
5. Acute inpatient admission neurological disorders. This medical necessity review involves MS-DRGs 068, 069, 070, 071, 072, 073, 074, 103, 312. RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly.
6. Anesthesia care and packaged E/M services. Identification of overpayments associated with evaluation and management services billed the day prior to or day of anesthesia services by an anesthesiologist. This involves E/M services billed the day prior to or day of anesthesia services without modifiers 24, 25, or 57 and E/M services billed the same day as 01996 without modifiers 24, 25 or 57.
7. Radiologists billing E/M services with diagnostic mammography. These are overpayments associated with radiologists billing evaluation and management services on the same date of service as diagnostic mammography services.
8. Verteporfin & ocular photodynamic therapy. This involves billing for Verteporfin (J3396) and ocular photodynamic therapy (67221-67225) without flourescein angiography (92235) or indocyanine-green angiography (92240) performed prior to each treatment.
9. Colonoscopy excess units. This involves billing for colonoscopy services with more than one unit of service. The CPT code descriptors for certain colonoscopy codes indicate the codes should only be billed once, even if multiple sites are treated using the same technique for the same beneficiary and same date of service.
9. Pulmonary diagnostic procedures and E/M services. This involves limited evaluation and management services (99211-99212) billed without modifier 25 on the same date of service as a pulmonary diagnostic procedure (94010-94799).
10. E/M services same day as allergy services. Identification of overpayments made for evaluation and management services billed without modifier 25 on the same date of service as allergy testing or allergen immunotherapy.
11. ECGs with cardiac catheterization procedures. An overpayment may exist when outpatient hospital providers bill separately for electrocardiograms performed the same date of service as cardiac catheterization procedures. ECGs performed prior to or after the cardiac catheterization should be billed with modifier 59.
12. Initial infusion services. Identification of overpayments associated with providers billing initial intravenous infusion (90765 and 96365), and subcutaneous infusion (90769 and 96369), with more than one unit of service by the same provider for the same beneficiary on the same date of service.
13. Procedures bilateral in nature. This involves payment for procedures that are bilateral in nature exceeding the price of a single unit of service.
14. Incorrect use of modifier 51 with CPT code 51797. Identification of underpayments associated with providers billing CPT code 51797 with modifier 51. CPT code 51797 is an add-on code that has a multiple procedure Indicator of 0 (no payment adjustment rules for multiple procedure reduction apply) and is therefore not subject to a payment reduction. Audit is looking at time period from Jan. 1 to June 30 2008.
15. Medically unlikely units table. This involves providers billing the same code in excess of units of service for the same beneficiary on the same date of service as stipulated in CMS MUE Table.
16. Add-on codes without paid required primary procedure. This involves claims for add-on codes when the required primary procedure is not billed on any claim for the same date of service.
Read the DCS postings of CMS-approved RAC issues.
Read more coverage on posting RAC audit issues:
Two RACs Post Audit Issues, But It's All Very Confusing
10 Tips on Improving RAC Readiness From Kaiser's RAC Expert
- 18 Findings from the Latest AHA Survey on RAC Activity