January 27, 2014 Drill Down – RAC Prepayment Reviews

 January 27, 2014

Drill Down – RAC Prepayment Reviews January 2014

In prior articles on RAC Prepayment reviews, I mentioned that this demonstration project, which began in September 2012, targeted several states whose claims historically resulted in high rates of improper payments. These were  seven states with high populations of fraud and error-prone provider claims (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO).  The purpose of this demonstration was to lower the improper payments before they occur and prevent the pay and chase model that exists now. This will allow the RAC to review the claims before they are paid. The Centers for Medicare & Medicaid Services (CMS) added to the Prepay Edits posted on its website for January 2014.

Prepayment Review Demonstration

January 15, 2014 - The following tables contain the most recent prepayment review updates:

Table 1 Prepay Edits

Period of Review	MS-DRG	Title
September 2012	MS-DRG 312	Syncope & Collapse
January 2013	MS-DRG 069	Transient Ischemia
March 2013	MS-DRG 377-379	G.I. Hemorrhage
May 2013	MS-DRG 637-639	Diabetes
June 2013	MS-DRG 252-254	Other Vascular Procedures
July 2013	MS-DRG 391-392	Esophagitis, Gastroenteritis, and Misc. Digestive Disorders
August 2013	MS-DRG 673-675	Other Kidney & Urinary Tract Procedures

Table 2 Prepay Edits

Month Began	Title
January 2014	Blepharoplasty  - (Inpatient Hospitals, Professional Services & Outpatient Hospitals)
	Skilled Nursing Facility and Coding Validation - (Skilled Nursing Facilities)
	Trastuzumab (Herceptin), multi-dose vial waste – (Outpatient Hospitals, Professional Services)
	Home Health – Medical Necessity & Conditions to Qualify for Services – (Home Health Agencies)
	J9310 Rituximab Dose vs. Units Billed – (Outpatient Hospital)
	Skilled Nurse Length of Stay – (Home Health Agencies)

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/RecoveryAuditPrepaymentReview.html

RAC Issues for the Week of January 27 – January 31, 2014:

No approved issues were posted to the RAC contractor websites.