This document discusses 5 target areas that Recovery Audit Contractors (RACs) are focusing on: 1. CMS has delayed the Medicaid RAC program implementation deadline to allow more state preparation. 2. RACs aim to detect and correct past improper Medicare payments to prevent future issues. They can review claims back 3 years and recover contingency fees from identified overpayments. 3. RACs were referred few potential fraud cases due to lack of incentive from contingency fees. 4. Providers should review documentation, coding, billing practices and educate staff to prevent RAC overpayment findings. 5. Common RAC focus areas include IV hydration coding, therapy evaluation codes, radiology billing, and Ne

1. RACs:5 Target AreasYour Group Needs to KnowJen Godreau, CPC, CPMA, CPEDCDirectorjenniferg@codinginstitute.com

2. Understand Alphabet Soup2/24/20112

3. 2/24/20113

4. CMS Delays Medicaid RAC ProgramSource: CMS Bulletin2/24/20114“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 BasicsPurpose: 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.2/24/20115

6. RAC Fraud2/24/20116Referred 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 TipsKnow findings of OIG CERTKnow findings of RAC Preliminary ProgramKnow plan of RAC Implementation ProgramKnow the target areas for your contractorIdentify your weaknessesReview documentation before paymentsReview documentation postpaymentEducate physicians, coders, billers2/24/20117

8. RAC Preliminary Findings2/24/20118Source: RAC Error Report

9. RAC Preliminary Findings2/24/20119Source: RAC Error Report

10. Top Overpayments!2/24/201110

11. IV HydrationRule: Should be billed with a maximum number of units (1) per patient per date of serviceSetting: Outpatient Hospital, PhysicianAffected 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 , initial2/24/201111CPT© 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 Unit2/24/20111296360 (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 serviceTypically 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 reasonBottomline: Reporting 96360 more than once on a single date of service is highly unlikely.

13. 1 Unit Maximum Exception2/24/201113Can 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

14. Guidelines2/24/201114Clear notation should exist for actual start and stop times for each bag, the route of administration, and whether a flush or hydration is performed.

15. If only a flush (clearing of lines) is performed, the procedure is not coded unless the flush occurs with medication. An IV push may be coded. Check for clear notation for actual start and stop times for each bag, route of administration, hydration is performed.

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.2/24/201115Action Plan

20. 2/24/201116Improper Documentation“over 1 hour”

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

25. times recorded that do not make sense (such as start time 6:39 with stop time 4:19) cannot be coded and thus should not be billed. 2/24/201117Know the Facts About Self AuditIf self-audit identifies improper payments, you should:report the improper payments to your MAC

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

27. 3 Often Missed Coding BasicsUntimed codes, excluding modifiers KX and 59. Bill one unit of these codes per date of service.

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.2/24/201118CPT© 2011 American Medical Association. All rights reserved.CPT® is a registered trademark of the American Medical Association. All rights reserved.

30. 2/24/201119Once in a LifetimeG0389 (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 AAAis a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetimeis a beneficiary who manifests other specified risk factors.

31. Global Billing of Radiology Codes in the Facility SettingRegion: RAC for Region A (DCS)

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