Get this guide to understanding RAC issues.
How good is your team at understanding recovery audit contractor (RAC) issues?
The mission of Centers for Medicare and Medicaid Services (CMS) and the RAC is to identify and correct Medicare improper payments for health care services provided to Medicare beneficiaries in all 50 states. These improper payments may be in the form of overpayments and underpayments.
Therefore, if you currently bill or have previously billed for one of the items listed below, you may be one of the reasons for RAC issues!
Currently, there are sixteen RAC issues listed on Performant’s website. Eight RAC issues will follow the automated review process while the other eight will follow the complex review process.
Most notably, the RAC will be conducting automated reviews on underpayments pertaining to Group 3 Power Wheelchair Options. This issue will seek to recover incorrect reductions owed to suppliers resulting from Section 2 of the Patient Access and Medicare Protection Act (PAMPA). To review affected codes, see Forms and Sample Documents, 0053-Region 5 Appendix E. Scroll to the bottom of the page and click on 0053-Reg Appendix E.
(For additional samples of documents providers can expect to receive from Performant Recovery, please click here.)
Approved RAC Issues
Nebulizers / Related Drugs and Accessories
Type of Review: Automated review
What’s the Issue? Overpayments have been identified where diagnosis codes not in accordance with billing requirements outlined in Local Coverage Determinations for Nebulizers, Related Drugs, and Accessories.
CPM Machines
Type of Review: Automated review
What’s the Issue? CPM billed without total knee replacement
Tracheotomy Suction Catheters, Suction Pumps, Catheters and Other Related Supplies / Equipment
Type of Review: Complex review
What’s the Issue? Overpayments have been identified where claims for pumps, suction catheters, and related supplies / equipment were not in accordance with billing requirements outlined in Local Coverage Determinations.
Chest Wall Oscillation Devices
Type of Review: Complex review
What’s the Issue? Potential incorrect billing occurred when claims for high-frequency chest wall oscillation devices were billed without an indication supporting medical necessity as described in the Nationwide Local Coverage Determination (LCD) L33785 and prior MAC LCDs L27042, L12934, L12870, L12739, all retired 9/30/2015 L12870 and related article (A25231).
Osteogenesis Stimulators
Type of Review: Complex review
What’s the Issue? Claims for osteogenesis stimulators that do not meet the indications of coverage and/or medical necessity will be denied.
Group 2 Support Surfaces without Correct Diagnosis of Condition
Type of Review: Complex review
What’s the Issue? Documentation will be reviewed to determine if Group 2 Support Surfaces meet Medicare coverage criteria, meets applicable coding guidelines, and / or is medically reasonable and necessary.
DME Billed While Inpatient
Type of Review: Automated review
What’s the Issue? A supplier (includes physician furnishing DME) may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two (2) days prior to the patient’s anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient’s home).
The item must be for subsequent use in the patient’s home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.
Glucose Monitor When Billed With the Same Date of Services as Glucose Monitor Supplies (Unbundling)
Type of Review: Automated review
What’s the Issue? Glucose Monitors Unbundling – HCPCS codes A4233, A4234, A4235, and A4236, which describe glucose monitor supplies, will be denied when billed with the same date of service as glucose monitor HCPCS codes E0607, E2100 or E2101.
Excessive Units of Spring Powered Devices Billed for >1 in a 6 Month Period
Type of Review: Automated review
What’s the Issue? Excessive Units of Spring Powered Devices: More than one spring powered device (A4258) per 6 months is not reasonable and necessary.
Multiple DME Rentals in One Month
Type of Review: Automated review
What’s the Issue? Overpayments associated to DMEPOS suppliers billing multiple rentals for the same equipment within the same month (27 days).
Hospital Beds with Mattresses Billed with Group I or Group II Support Mattresses
Type of Review: Automated review
What’s the Issue? Billing for hospital beds with mattresses and Group I or II support mattress constitutes billing for the same or similar equipment.
Medical Necessity and Complex Coding Nebulizer
Type of Review: Complex review
What’s the Issue? Documentation will be reviewed to determine if the Nebulizers, Compressors, Related Drugs, and Accessories meet Medicare coverage criteria, meet applicable coding guidelines, a validation of the drug dosage administered versus dosage billed, and/or are medically reasonable and necessary.
Complex Comprehensive Negative Pressure Wound Therapy Pumps
Type of Review: Complex review
What’s the Issue? Medical Necessity Review Negative Pressure Wound Therapy Pumps – Potential incorrect billing occurred when claims for Negative Pressure Wound Therapy Pumps were billed without an indication supporting Medical Necessity as outlined in NHIC’s Local Coverage
Complex Blood Glucose Monitors with Integrated Voice Synthesizer Billed Without Indicator of Medical Necessity
Type of Review: Complex review
What’s the Issue? Blood Glucose Monitors with Integrated Voice Synthesizer – Medical documentation will be reviewed to determine if claims for voice synthesized blood glucose monitors were billed without an indication supporting medical necessity. The affected code is E2100.
Group 3 Power Wheelchair Options Underpayments
Type of Review: Automated review
What’s the Issue? Section 2 of the Patient Access and Medicare Protection Act (PAMPA) mandates that adjustments to the 2016 Medicare fee schedule amounts for certain DME based on information from competitive bidding programs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs. Group 3 complex rehabilitative power wheelchair bases are currently described by codes K0848 through K0864. Although this PAMPA change is effective January 1, 2016, Medicare could not implement changes to claims processing systems prior to July 5, 2016. Until then, payment for these items will be based on the adjusted fee schedule amounts. This issue recovers the incorrect reductions owed to suppliers for claims for these items for DOS 1/1/2016 – 6/30/2016. For Affected Codes, see Forms and Sample Documents, 0053-Region 5 Appendix E.
This is a guest post by Sharon Briggman, Prochant’s Director of Training & Compliance.
Prochant is the nation’s leading HME billing and process outsourcing company. Our highly-skilled team helps providers become more profitable by outsourcing or enhancing front- and back-office processes. We rapidly implement changes and proactively monitor metrics to ensure client success. Headquartered in Charlotte, North Carolina, we work with top medical equipment providers and health systems.