This week I have been working with one of our nurse reviewers on a case for a client in the Highmark Medicare Services, Inc. MAC district. A patient has been receiving HBO therapy and services were paid by Highmark for sessions one and two, but session three provided on 6/17/2011 was denied via EOB as reason code 50 Not Medically Necessary. The cliams for all three sessions carried the ICD-9-CM diagnosis code of 990 Effects Of Radiation, Unspecified. So, of course, the first place we went was the CMS Coverage Database to review any NCDs or LCDs for HBO therapy and in fact, there is an NCD for HBO therapy (20.29). The NCD lists both osteoradionecrosis and soft tisuue radionecrosis as conditions that are covered for HBO therapy. The NCD itself, however, does not list specific ICD-9-CM codes.

On to the LCDs. Using the CMS database we found that Highmark issued an LCD for HBO therapy that went into effect, wouldn’t you know it, on 6/17/2011, the same date as the denied service. We quickly scanned the LCD looking for the inclusion or exclusion of ICD-9-CM 990. It wasn’t included on the list of covered ICD-9-CM codes for HBO therapy! It seemed to us that it should have been there as a covered diagnosis. Well, now we knew we were dead in the water. There really wasn’t a chance for appeal when the LCD does not include the ICD-9-CM code for this patient as a diagnosis that supports medical necessity. If I had stopped there, I would have had to tell the client that there was no chance for appeal, but this just did not seem fair. The patient had already been receiving HBO therapy that was being paid by CMS and now suddenly therapy would no longer be covered. I realize that LCDs have to have an effective date, but this just didn’t seem right.

So the nurse reviewer and I did some more digging. Going back to the NCD, under ‘Revision History’ I found a transmittal (TN 164 – CR 2388) that indicated that ICD-9-CM 990 is a covered diagnosis for HBO therapy. Since LCDs are not allowed to be more restrictive than an NCD, I knew we had the evidence we needed to appeal this HBO denial. The funny thing that happened though is that the nurse reviewer went on the Highmark website and looked at the HBO LCD (L32018) for services performed on or after 6/17/2011 (the same one posted on the CMS website) and ICD-9-CM 990 was included in the list of covered diagnosis! And in fact, the revision history for the LCD included a revision made on 6/17/2011, the same day the LCD went into effect, that reads “Revision effective for dates of service on and after 06/17/2011. ICD-9 code 990 added for coverage”. Well, what do you know? The LCD from the Highmark website will make it even easier to appeal.

What I learned is this, if it doesn’t seem right, it probably isn’t. Just keep digging and you’ll find the right answer. I guess I also need to rethink my standard teaching method of always accessing the LCDs from the CMS database. I now know there may be times when I need to look at both the CMS database and the FI or MAC website. Just shows you what a little digging and a refusal to accept ‘No’ for an answer will get you! And kudos to the nurse reviewer who worked with me on this!

This publication also includes the top overpayment issue by RAC Region. Region A’s top issue is incorrect coding of ventilator hours. Region B’s top issue is incorrect coding of Extensive Operating Room Procedure Unrelated to Principal Diagnosis, specifically, reporting an incorrect principal and/or secondary diagnosis. Regions C and D both share a top issue of Billing for Bundled Services Separately, specifically, DMEPOS provided during an inpatient stay.

As usual, CMS has given us a bare minimum of information without a lot of insight, but the publication is worth a peak. You can find it at http://www.cms.gov/RAC/Downloads/FFSNewsletter.pdf.

You can find the revised forms by going to http://www.cms.gov/CMSForms/CMSForms/list.asp#TopOfPage
and clicking on the First Level of Second Level appeal page. The forms
are under the ‘Download’ area. Or click here:

http://www.cms.gov/OrgMedFFSAppeals/Downloads/CMS20027a.pdf
http://www.cms.gov/OrgMedFFSAppeals/Downloads/CMS20033a.pdf

The form to request a hearing at the ALJ level did not change.

Of course, you do not need to use a form to request an appeal as long
as your appeal request includes the elements required by CMS. For
exmaple, a request for a redetermination must include:

1. Beneficiary name;
2. Medicare health insurance claim (HIC) number;
3. The specific service(s) and/or item(s) for which the
redetermination is being requested;
4. The specific date(s) of the service; and
5. The name and signature of the party or the representative of the
party.

However, if you currently use the CMS forms, you now know that the
forms have been revised and can be found in the CMS website, but not
in the ususal location.

As always, best of luck on your appeals!

On another note, CMS recently reported an audit issue not specifically RAC related in the form of an MLN Matters® (7170) published November 12, 2010, titled Reporting of Modifiers and Revenue Codes on Claims for Therapy Services. This MLN Matters® refers to the use of the GN, GO, and GP modifiers when billing therapy services under an outpatient rehabilitation plan of care. CMS has determined that these codes are not always used in a correct and consistent manner. For example, CMS has found outpatient rehabilitation claims that report both a GO and GP modifier for the same service.

CMS states that not only do these claims represent non-compliant billing by outpatient rehabilitation providers, but they also make it difficult for CMS to analyze claims data for purposes of Medicare program improvements. And we know CMS has a lot of program improvement initiatives (i.e., audit activities) in place. So, effective April 1, 2011, CMS will have an edit in place to indentify the incorrect use of the therapy modifiers. Claims identified with incorrect modifiers will be returned to the provider for correction.

This issue should be easy to spot by data mining your claims database, although I would hope most providers or claims clearinghouses would already have an edit in place to catch this type of error before it reaches the payer.

You should also consider data mining for the correct modifier per therapy services to identify any issues there since revised wording in CMS Publication 100-4 Medicare Claims Processing Manual, Chapter 5, Section 20.1 indicates that claims containing revenue codes 042X, 043X, or 044X without therapy modifier GN, GP, or GO will also be returned to the provider.

And contractors are also instructed to return to the provider any claims with a mismatch of revenue code to modifier. In other words, revenue code 042x (physical therapy) lines may only contain modifier GP, and so forth.

Doing the investigative work now and correcting any identified issues or patterns may save you some headache come April 1, 2011.

You can access the MLN Matters® 7170 at: http://www.cms.gov/MLNMattersArticles/downloads/MM7170.pdf.

In the ongoing quest to answer the question of whether the RAC can audit the same claim multiple times, one FAQ was updated and a new FAQ was posted.

FAQ # 10007, which reads, “Can the Recovery Audit Contractor (RAC) do a medical necessity review on a claim that they originally reviewed for DRG validation?” was updated.

And the answer is: “Beginning November 1, 2010 if the RAC has already requested documentation and issued a review results letter to the provider for a DRG Validation, the RAC will be allowed to re-review the claim again for medical necessity. However, if both issues are approved (DRG Validation and medical necessity) prior to the request of the additional documentation, the RAC may also conduct both reviews simultaneously. Each additional documentation request (ADR) is subject to the same review timeframes and counts toward the provider’s ADR limit.”

Listed as ‘New’, but originally published 11/2/2010, FAQ # 10239 reads: “Can a Recovery Audit Contractors (RAC) review a claim more than once?”

And the answer is: “The RAC can review a claim either through automated or complex review more than once. The exact claim line cannot be reviewed more than once but the RAC may review different claim lines in separate reviews. In addition, the RAC may conduct a DRG Validation review and then separately request documentation to complete a medical necessity review.”

So, it sounds as if a new ADR will be issued if the RAC has already reviewed and provided a results letter for a DRG validation issue and then wants to review the claim again for medical necessity. However, if you’ve already sent the complete medical record in for the DRG validation audit, will you have to send the record in again? If so, I hope you scanned and saved your hybrid medical record as an electronic document so you can easily retrieve it and send it on again to your RAC. Will you get reimbursed for the copying of the medical record and first class postage a second time, I wonder?

Anyway, it appears as if the only thing we can be sure won’t be reviewed more than once by the RAC is an exact claim line. Let’s hope our review results letters and/or demand letters are clear on which exact claim lines were reviewed so we can flag and track this data ourselves.

The other FAQs that were updated or new last week include two updated FAQs (# 7734 and # 7735) that explain who providers should contact with questions concerning RAC communications. FAQ # 7734 indicates that providers should contact the RAC customer service line first, but if the RAC customer service line does not answer your questions and/or concerns, then a provider can contact CMS through the email address RAC@cms.hhs.gov.

Additionl new or updated FAQs:

FAQ # 10260:  “I am participating in a CMS demonstration. Are my claims exempt from Recovery Audit Contractors (RAC) review?”

Answer # 10260: “At times CMS does grant temporary exemptions from RAC review for CMS sponsored demonstrations. However, all demonstrations do not get an exemption. The demonstration contractor or CMS will alert providers if their claims are exempt from RAC review during the demonstration. This alert can usually be found in the initial welcome letter. Questions can be directed to the contractor performing the demonstration.”

FAQ # 7738: “Will the Recovery Audit Contractors (RAC) review evaluation and management (E&M) services on physician claims under Part B?”

Answer # 7738: “Yes, the review of all evaluation and management (E & M) services will be allowed under the RAC program. The review of duplicate claims or E & M services that should be included in a global surgery were available for review during the RAC demonstration and will continue to be available for review. The review of the level of the visit of some E & M services was not included in the RAC demonstration. CMS will work closely with the American Medical Association and the physician community prior to any reviews being completed regarding the level of the visit and will provide notice to the physician community before the RACs are allowed to begin reviews of evaluation and management (E & M) services and the level of the visit.”

You can access CMS FAQs at the following link: http://questions.cms.hhs.gov/. Enter ‘RAC’ in the Search function to access the RAC-specific FAQs.

• The biggest single waiver, for 351,000 people, was for the United Federation of Teachers (UFT) Welfare Fund, a New York union providing coverage for city teachers. Coincidentally the American Federation of Teachers, parent company of UFT, gave hundreds of thousands of dollars to Healthcare for America Now, the leading organization pushing for the government takeover of health care. I wondered if they are still enamored with the monstrosity now.

• Overwhelmingly American’s want this legislation repealed. You cannot ignore the laws of economics and just wish for a different result.

• In an unrelated note the Social Security’s inspector general reported that the government sent out 89,000 checks of $250 each to deceased and incarcerated Americans as part of last year’s so-called stimulus package. The funds, totaling around $22.3 million, were sent out in May of last year, with $4.3 million going to 17,000 incarcerated Americans and $18 million to people who had already died. Of course the dead are a big Democrat voting bloc in places like Chicago and Philadelphia.

• When ObamaCare kicks in fully the government will be sending an estimated 10 million American’s checks to subsidize their cost of healthcare. Do we really want the inept federal government in control of our healthcare? They can’t even mail out $250 checks to people and they will be deciding who gets care and who does not. Scary.

All issues of the newsletter will be available on the CMS website. You can access it through CMS Home>Research, Statistics, Data and Systems>Recovery Audit Contractor>Recent Updates. Or you can access it through CMS Home>Outreach and Education>MLN Products>MLN Publications. Once there you will need to use the ‘Sort’ features in order to find the newsletter. Beware, the Sort by Date function sorts the dates alphabetically not numerically. For example, if you sort by Date Descending, September 2010 through 2004 comes up first in the list. But October 2010 comes up next which is the date of the newsletter. Searching for items containing the word ‘compliance’ will also bring up the newsletter.

The newsletter is structured to describe an issue, the problems that may occur as a result of the issue, the steps CMS has taken to make providers aware of the issue, and the recommendations on what providers need to do to avoid the problem. I read this 12-page newsletter front to back and the descriptions of the issues and the recommendations are not very enlightening. The recommendations especially are repetitive and routine. For example, the recommendation of having one person and a back up identified as being responsible for dealing with and monitoring the RAC process, monitoring the RAC websites regularly, and paying close attention to accurate billing were mentioned several times for many different issues. I don’t imagine there are very many providers out there that haven’t already implemented these recommendations.

Even though I consider myself well-versed in the RAC process I still try to read everything CMS publishes in regard to the RAC and coverage issues in general. It’s part of being a detective and ‘following all leads’ so I make sure I am as informed as I can be. One thing that is helpful in this newsletter is the inclusion of links to other CMS documents that provide additional information on the issues identified and general coverage guidelines. This is where I take the time to follow all these links and make sure I have these guidelines bookmarked or printed and saved to my RAC reference library. You never know when you might need to refer back to these when working your appeals.

Finally, I just have to comment that someone at MLN did a fine job of including numerous photos of handsome, happy healthcare providers adorned with stethoscopes, computers, and patient charts looking out at us from the newsletter. It reminds me that despite all the challenges we face with regulations and reimbursement, it’s still a great feeling to work in the world of healthcare. If that was the intent of the artwork, then it did its job.

You can read the first edition of the newsletter at http://www.cms.hhs.gov/MLNProducts/downloads/MedQtrlyComp_Newsletter_ICN904943.pdf

The program is supposed to offer health insurance to people with medical problems at prices that the average healthy person would pay which is not really cheap. The program will last until 2014, when the new health law will require insurers to accept all applicants regardless of medical history.

But to the surprise of some the Pre-Existing Condition Insurance Plan started this summer isn’t living up to expectations. Enrollment lags in many parts of the country. California, which has money for about 20,000 people, has received fewer than 450 applications, a state official reported. The program in Texas had enrolled about 200 by early September, an official there said. In Wisconsin, Goldman said the agency has received fewer than 300 applications so far, with room for about 8,000 people in the program. Government economists projected as recently as April that 375,000 people would gain coverage this year, and they questioned whether $5 billion allocated to the program would be enough

Could it be that Obama’s definition of affordable is not the same as the average American’s definition? Or could it be that many American’s thought that this coverage would be free? Or perhaps people with pre-existing conditions are waiting until they actually have medical bills to buy the insurance? I suspect all three are behind this.  

The later is one of the major flaws of ObamaCare. If you can opt to delay purchasing insurance until you really need it then it is more of a just in time welfare program than traditional insurance. This is just another warning sign of problems that we will face with this disastrous legislation.

MLN Matters article SE 1027, titled “Recovery Audit Contractor (RAC) Demonstration High-Risk Medical Necessity Vulnerabilities for Inpatient Hospitals” is designed to provide education to hospitals about the vulnerabilities (read ‘medical necessity errors’) identified during the demonstration project to prevent the same problems from occurring again.

This MLN Matters article includes a table of 17 improper payment findings from the demonstration project by issue and DRG, ranked in order from top to bottom by improper payment amount, pre-appeal. I’ve taken that list and expanded it here to include the current MS-DRG assignment and which RACs are currently auditing for these issues. (Hint: These published issues are updated frequently. Check your RAC region website for the most up to date information.) If you haven’t started your internal audits to assess your RAC risk, this might be a good list to start with.

 Improper Payment Amount (pre-appeal) RAC Demonstration Findings and Current RAC Published Issues

 * Not a direct crosswalk.

Whether you are new to the RAC process or well-versed and entrenched in the system as I am, this article provides some good insight into how CMS views documentation of medical necessity in the patient record. This is the type of information I like to have readily at hand when I am working on appeals. SE1027 includes a handful of hyperlinks to CMS resources which I recommend you bookmark or print to your reference library as well as you may find them very helpful when working on your appeals.

MLN Matters article SE1028 is titled “Recovery Audit Contractor (RAC) Demonstration High-Risk Diagnosis Related Group (DRG) Coding Vulnerabilities for Inpatient Hospitals.” Again, the purpose of this article is to provide education on RAC demonstration-identified inpatient hospital coding vulnerabilities. The four high-risk coding issues identified were:

• Respiratory System Diagnosis with Vent support (CMS DRG 475, now MS-DRG 207, 208)
• Closed Biopsy of Lung (CMS DRG 076, 077,120, now MS-DRG 166, 167, 264)
• OR Procedure for Infections, Parasitic Diseases (CMS DRG 415, now MS-DRG 853, 854, 855)
• Coagulopathy (CMS DRG 397/143, now MS-DRG 813)

Essentially, during the demonstration project, CMS found that what was billed did not match documentation in the chart.

And as you prepare your charts for RAC review, I encourage you to pay special attention to the last paragraph in the SE1028 article that states “CMS reminds providers to ensure that any information that affects the billed services and is acquired after physician documentation is complete, must be added to the existing documentation in accordance with accepted standards for amending medical record documentation.”

Use these links to access the MLN Matter articles:

 http://www.cms.gov/MLNMattersArticles/downloads/SE1024.pdf

http://www.cms.gov/MLNMattersArticles/downloads/SE1027.pdf

http://www.cms.gov/MLNMattersArticles/downloads/SE1028.pdf

Question: CMS does not define “accepted standards for amending medical record documentation.” How would you define the “accepted standard?”

There was much spin control after this story. Both Obama administration and McDonalds denied the allegations. Sympathetic journalists use terms like “unintended consequences” when stories like this surface. There is nothing surprising or unintended about this. First of all ObamaCare was a bill that was over 1,000 pages. Secondly, few legislators read the bill. And finally Obama’s real agenda is a one payor government run system. Obama’s constant contention that “if you are happy with your current plan you can keep it” was and is a major deception.

Where did the number for the medical loss ratio of 80% to 85% come from? It is quite arbitrary and was probably inserted by some young idealistic legislative aide who is clueless about the industry. I am sure that several such arbitrary requirements will surface as this bill unravels on the masses. While this target may be reasonable for some large employer plans with a stable work force, it is not reasonable for the mini-med plans in industries with high turnover like McDonalds.

The Obama administration indicated yesterday (9/30/10) that they are open to discussing this and said that Kathleen Sebelius has the discretion to deal with this. That is a big change from Sebelius’s recent stern warning to insurers to not blame cost increases on ObamaCare.

Elections are important. The best that we can hope for is a repeal of this government takeover of our healthcare.