In Context

RAC Drill-Down – Dose vs. Units: Recoupment Coming Your Way

April 2, 2013

 In the March 26, 2013 posting for RAC Region A Performant, the drug code J9055 Cetuximab, an epidermal growth factor inhibitor used for metastatic colorectal cancer and some head and neck cancers now impacts the following states of DE, MD, NJ, PA and DC. This semi-automated audit describes the potential for incorrectly billing Cetuximab with diagnosis codes that do not support medical necessity. An important reimbursement note for this drug is that this code represents 10 mg per unit, therefore when billing for this drug bill one 1 unit for every 10 mg per patient. The recoupment will occur when documentation supporting medical necessity is not received from the provider within the 45 day response period.

A semi-automated reviews drills into your claim data and profiles your claim much like what the credit card companies do to you when you make high purchases in one state and then make more purchases in another. It is a pattern that most likely points to fraud or abuse. Now that you are on the RAC semi-automated radar screen they will send you an “informational” letter which looks just like all the other letters you get for audits. This one has “informational” on it.  You will have only 45 days to file more clinical documentation proving medical necessity to overturn their decision. The RAC has 60 days to either reverse their finding or forward the file to the MAC for recoupment.

Getting the correct diagnosis is the key to avoid semi-automated reviews as well providing the supporting clinical documentation to justify your claim’s medical necessity. Semi-automated reviews will not only involve your RAC team but most likely your clinical staff. An important step is to correct any documentation deficiencies along with any coding errors if they are found on post-payment claim reviews to prevent current claims and documentation to continue with these patterns.

Other RAC issues for the week of March 25^th – 29^th, 2013:

RAC Region A Performant

Physician/Non Physician Practitioner Claim Types

 

§  Hyaluronic Acid – J12 Potential incorrect billing occurred for hyaluronic acid claims billed with an ICD-9-CM code that does not support medical necessity, according to existing Medicare policy, FDA labeling, accepted guidelines, approved compendia, or other Medicare rules and regulations. Payments will be recouped when no additional documentation is received from the provider for complex review within the 45-day response period.

 

DME Claim Types

 

§  Patient Lifts – DME Jurisdiction A Potential incorrect billing occurred when claims for patient lifts were billed without an indication supporting Medical Necessity as described in the Medicare National Coverage Determination, IOM Publication 100-03, Chapter 1, Part 4, Section 280.1, and the NHIC Local Coverage Determination (LCD) L5064 and related article (A23657).

RAC Region D HDI

ASC Claim Types

 

§  Injections Not Supported by Diagnosis – J1 Injections of the Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma not supported by Diagnosis for J1.