9.1.10 – Region C RAC begins medical necessity reviews NEW

The Medicare Recovery Audit Contractor for Region C – Connolly Healthcare – has begun medical necessity reviews for 18 types of inpatient hospital conditions, which are listed on its website. The Region C states are: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia. On Aug. 6, the Centers for Medicare & Medicaid Services’ New Issue Review Board gave the four regional RACs approval to begin medical necessity reviews for 18 inpatient hospital conditions. RACs are authorized to begin requesting medical charts for medical necessity review audits after announcing the audits on their websites. To date, RACs in all but Region A have announced medical necessity review audits. The AHA encourages hospitals to continue monitoring their RAC’s website for newly emerging information on these and other RAC audits. Contact information for the four regional RACs can be found at www.aha.org/aha/issues/RAC/contractors.html.

8.13.10 – News on the Medicare RAC Program

The Centers for Medicare & Medicaid Services’ (CMS) Medicare Recovery Audit Contractor (RAC) program is now operating in every state in the nation. The AHA continues to work with CMS to address issues and concerns pertaining to the execution of the RAC program and related activities by CMS-contracted Medicare administrative contractors and fiscal intermediaries. This Update provides information regarding the commencement of medical necessity reviews in RAC Region B.

CGI Technologies and Solutions, Inc. – the RAC for Region B – yesterday issued a list of the 18 medical necessity reviews recently approved by CMS for audit. CGI on Aug. 6 received approval from CMS’ New Issue Review Board to begin auditing the 18 inpatient hospital claims listed below. CGI has begun posting these audits to its RAC webpage and will soon begin requesting medical records for these audits. The information below will be provided on the CGI website, in addition to related details per condition, such as the particular MS-DRGs and specific Medicare policies to be considered for these medical necessity reviews.

The 18 approved medical necessity reviews are:

• Chest Pain
• Other Circulatory System Diagnoses, w/ MCC
• Other Vascular Procedures, w/ CC, w/o CC/MCC
• Syncope & Collapse
• Red Blood Cell Disorders, w/ MCC
• Atherosclerosis w/ MCC
• Heart Failure & Shock, w/MCC, w CC and w/o CC/MCC
• Esophagitis, Gastroenteritis & Misc Digestive Disorders, w/ MCC
• Musculoskeletal Disorders*
• Chronic Obstructive Pulmonary Disease
• Respiratory*
• Nutritional and Metabolic Disorders
• Kidney & Urinary Tract Infections, w/MCC
• GI Disorders*
• Percutaneous Cardiovascular Procedures
• Renal Failure
• Nervous System Disorders*
• Cardiac Arrhythmia & Conduction Disorders, w/MCC or w/CC*

* medical necessity reviews excluded for some MS-DRGs associated with this condition

Next Steps
The AHA encourages hospitals in the other three RAC regions to monitor their RAC’s website for information on medical necessity audits. At this time, we are waiting for details on the number and type of medical necessity reviews approved by CMS for RACs in regions A, C and D. Contact information for the four regional RACs is below.
RAC Region A
Diversified Collection Services, Inc.
Livermore, California
1-866-201-0580
Email: info@dcsrac.com
Website: www.dcsrac.com

RAC Region B
CGI Technologies and Solutions, Inc.
Fairfax, Virginia
1-877-316-RACB
Email: RACB@cgi.com
Website: racb.cgi.com

RAC Region C
Connolly Consulting Associates, Inc.
Wilton, Connecticut
1-866-360-2507
Email: RACinfo@connollyhealthcare.com
Website: www.connollyhealthcare.com

RAC Region D
HealthDataInsights, Inc.
Las Vegas, Nevada
Part A: 866-590-5598
Part B: 866-376-2319
Email: racinfo@emailhdi.com
Website: racinfo.healthdatainsights.com

Further Questions
For more information on the RAC program, visit www.aha.org/rac

Source: American Hospital Association

2.19.10 – Region D Medicare Recovery Audit Contractor Posts New Issues for DRG Validation

HealthDataInsights, Inc. (HDI), the Medicare recovery audit contractor (RAC) for Region D, recently posted new CMS approved audit issues for RAC review pertaining to Part A inpatient claims and DRG validation.  According to the HDI website, the issues include:

• Breast Procedures
• Cardiovascular (Other)
• Nose, Mouth & Throat Disorders
• Endocrine, Nutritional & Metabolic Procedures
• Eye Disorders
• Female Reproductive System Disorders
• HIV Infections
• Infection (Other)
• Joint Procedures
• Male Reproductive System Disorders
• Musculoskeletal Disorders
• Musculoskeletal Fractures
• Skin Disorders
• Disorders Related to Injuries (Toxicity)

The issues apply to all states within Region D.  Region D includes Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa, and Northern Marianas.

The issues also include a statement that medical necessity is excluded from review at this time.

2.12.10 – Region B and D Medicare RACs Post New Audit Issues

CGI, the Medicare recovery audit contractor (RAC) for Region B, recently added a new CMS approved audit issue for RAC review pertaining to inpatient claims and MS-DRG validation. The new issue is titled Spinal Procedures Neurostimulators W CC or MCC and it applies to all states within Region B. Region B includes the states of Minnesota, Wisconsin, Michigan, Illinois, Indiana, Ohio and Kentucky.

HealthDataInsights, Inc. (HDI), the Medicare recovery audit contractor (RAC) for Region D, recently posted new CMS approved audit issues for RAC review on its website.  The following issues were added to the list:

• OP Services Within 72 Hrs of Admit (Part A Outpatient)
• Acute Readmissions – No B4 (Part A Inpatient)
• Incorrect Patient Status – IRF (Part A Inpatient Rehabilitation Hospitals)
• Medically Unlikely Edits (Part A Outpatient, Part B, DME)

The above issues apply to all states within Region D. Region D includes Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa, and Northern Marianas.

2.5.10 – CMS Modifies RAC Additional Documentation Request Limits

The Centers for Medicare & Medicaid Services (CMS) recently modified its fiscal year 2010 additional documentation request limitations for the Medicare Recovery Audit Contractor (RAC) program.

Specifically, CMS has expanded the policy on additional documentation request limits so that it now applies to reviews of all institutional claim types.  The limits announced in December 2009 applied only to requests for DRG validation purposes; the same methodology will now be used for reviews of all institutional claim types. CMS will post the limits for physicians, non-physicians practitioners and DMEPOS suppliers at a later date.

For more information, see the new document titled Additional Documentation Limits for FY2010 for Institutional Providers. Additional information on the RAC Program audits can be found at the CMS RAC webpage.

1.22.10 – Region B and D Medicare RACs Continue to Add CMS Approved Audit Issues

1.  HealthDataInsights, Inc. (HDI), the Medicare recovery audit contractor (RAC) for Region D, recently posted new CMS approved audit issues for RAC review on its website.

HDI added 5 new CMS approved audit issues pertaining to Medicare Part B claims, which apply to all states within Region D. Region D includes Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa, and Northern Marianas.

The recent approved issues are:

• Clinical Social Worker (CSW) Services During Inpatient Stay
• NCCI Edits
• Hospice Related Services – B
• TC of Radiology
• Not a New Patient – Providers are only allowed to bill the CPT codes for New Patient visits if the patient has not received any professional services from the physician or physician group practice within the previous 3 years.

For more information refer to the HDI website.

2.  CGI, the Medicare recovery audit contractor (RAC) for Region B, recently updated its CMS approved audit issues for RAC review.

Specifically, CGI expanded its CMS approved audit issues for outpatient hospitals and professionals in all Region B states. Region B includes the states of Minnesota, Wisconsin, Michigan, Illinois, Indiana, Ohio and Kentucky.

The recent update to the CMS approved audit issues include:

• Intravenous Infusion Chemotherapy and Non-Chemotherapy – Excessive Units Reported
• Preadmission Testing
• Separately Paid Ambulance Service during Inpatient Hospitalization Review

CGI also added the issue of Hospital to Hospital Transfer for inpatient hospitals.

For more information, refer to the CGI’s website.

1.15.10 – Region C Recovery Audit Contractor Posts Additional Audit Issues for DRG Validation

Region C Recovery Audit Contractor Posts Additional Audit Issues for DRG Validation

Connolly Healthcare, the Medicare recovery audit contractor (RAC) for Region C, recently updated its CMS approved audit issues for RAC review.

Specifically, Connolly Healthcare recently posted at least 21 new CMS approved audit issues on its website for inpatient hospitals pertaining to DRG validation.

The issues affect providers in the states of Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee and Texas.

The issues are briefly described below:

• Other Vascular Procedures with MCC: MS-DRG 252
• Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574
• Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573
• Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without CC/MCC: MS-DRG 465
• Other Digestive System O.R. Procedures with MCC: MS-DRG 356
• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG 623
• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG 622
• Other Digestive System O.R. Procedures with CC: MS-DRG 357
• Other Hepatobiliary or Pancreas O.R. Procedures with MCC: MS-DRG 423
• Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578
• Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576
• Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575
• Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC: MS-DRG 464
• Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC: MS-DRG 463
• O.R. Procedure with Diagnoses of Other Contact with Health Services with CC: MS-DRG 940
• O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC: MS-DRG 939
• Other Circulatory System O.R. Procedures: MS-DRG 264
• Cardiac Pacemaker Revision Except Device Replacement without CC/MCC: MS-DRG 262
• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC: MS-DRG 624
• Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260
• Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256

All of the above issues include a statement that medical necessity is excluded from review at this time.

1.8.10 – Region C Medicare Recovery Audit Contractor Adds New CMS Approved Audit Issue

Region C Medicare Recovery Audit Contractor Adds New

CMS Approved Audit Issue

Connolly Healthcare, the Medicare recovery audit contractor (RAC) for Region C, recently posted new CMS approved audit issues for RAC review on its website. Please refer to each approve issue for applicability to your state. Region C includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, Virgin Islands and West Virginia.

The titles for the new CMS approved audit issues are:

APPROVED ISSUE — MS-DRG (if applicable)

1.    Other Kidney and Urinary Tract Procedures with MCC (At this time Medical Necessity excluded from review)  –  673
2.    Wound Debridements for Injuries without CC/MCC (At this time Medical Necessity excluded from review)  –  903
3.    Wound Debridements for Injuries with MCC (At this time Medical Necessity excluded from review)  –  901
4.    Wound Debridements for Injuries with CC (At this time Medical Necessity excluded from review)  –  902
5.    Postoperative or Posttraumatic Infections with O.R. Procedure with MCC (At this time Medical Necessity excluded from review)  –  856
6.    Postoperative or Posttraumatic Infections with O.R. Procedure with CC (At this time, Medical Necessity excluded from review)  –  857
7.    Infectious and Parasitic Diseases with O.R. Procedure with MCC 853 (At this time, Medical Necessity excluded from review)  –  853
8.    Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC (At this time Medical Necessity excluded from review)  –  858
9.    Infectious and Parasitic Diseases with O.R. Procedure with CC (At this time Medical Necessity excluded from review)  –  854
10.    Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC (At this time Medical Necessity excluded from review)  –  855
11.    O.R. Procedure with Principal Diagnoses of Mental Illness (At this time Medical Necessity excluded from review)  –  876
12.    Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC (At this time Medical Necessity excluded from review)  –  928
13.    Other Kidney and Urinary Tract Procedures with CC (At this time Medical Necessity excluded from review)  –  674
14.    Nonextensive Burns (At this time Medical Necessity excluded from review)  –  935
15.    Peritoneal Adhesiolysis with MCC (At this time, Medical Necessity excluded from review)  –  335
16.    Barium Swallow Studies Units Billed  –  Outpatient service
17.    Adenosine – Dose vs. Units billed  –  Outpatient service
18.    Nebulizer, Demonstration and Evaluation Units Billed  –  Outpatient service

More information on the new CMS approved audit issue for Region C can be found here.

12.28.09 – Region C Medicare Recovery Audit Contractor Adds New CMS Approved Audit Issue

Connolly Healthcare, the Medicare recovery audit contractor (RAC) for Region C, recently posted a new CMS approved audit issue for RAC review on its website.

The title of the new CMS approved audit issue is “Medically Unlikely Edit List” and it applies to all states and territories in Region C. Region C includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, Virgin Islands and West Virginia. The provider type affected is outpatient hospitals.

More information on the new CMS approved audit issue for Region C can be found here.

12.24.09 – Region A Medicare Recovery Audit Contractor Adds New CMS Approved Audit Issues

DCS Healthcare (DCS), the Medicare recovery audit contractor (RAC) for Region A, recently posted new CMS approved audit issues for automated RAC review on its website.

The titles of the new CMS approved audit issues are listed below and apply to DMEPOS suppliers in all states within Region A:

• Solid Insert with Seat or Back Wheelchair Cushions
• Lower Limb Suction Value Prosthesis
• Prosthetic Additions with Initial or Preparatory Knee Prosthesis
• Multiple DME Rentals within a Month
• Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain’s Chair Seat
• Wheel Attachment with New Non-Wheeled Walker

Region A includes Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

For more information, see the CMS approved audit issues for Region A, which can be found here.

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