Lyman Sornberger Executive DirectorCleveland Clinic Health System Patient Financial ServicesCheryl ArnoldSenior Director, Business Development and TrainingCleveland Clinic Health System Patient Financial ServicesRebecca Stewart, CCS, CPCProject Manager, Business Development Cleveland Cli
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1. Are you Ready to RAC and/or Roll Over?
2. Lyman Sornberger Executive Director
Cleveland Clinic Health System Patient Financial Services
Senior Director, Business Development and Training
Cleveland Clinic Health System Patient Financial Services
Rebecca Stewart, CCS, CPC
Project Manager, Business Development Cleveland Clinic Health System Patient Financial Services
3. What not to do? Our Florida Experience was Out of Tune
4. Purpose of RAC The RAC programs mission is to reduce Medicare improper payments through:
The efficient detection and collection of overpayments
The identification of underpayments and
The implementation of actions that will prevent further improper payments
5. Medicare Error Rate in 2007
6. CMS Claims Review Entities
7. What did RAC Recover?
8. CMS Return on Investment
9. Automated Reviews RAC makes a claim determination at the system level without human review of the medical record
Coverage / coding determination made through automated review when the following applies:
Certainty the service is not covered or is incorrectly coded, AND
Written Medicare policy
or Medicare sanctioned coding guidelines exist
CPT Assistant Statements
Coding Clinic Statements
Other determinations made through automated reviews
Discharge Disposition / Transfer DRG
10. Complex Reviews
11. RAC Appeals by Contractor
12. CMS National Rollout Plan September 2008
13. How is the permanent RAC different?
14. Improper Payments excluded from Statement of Work Excluded
Services provided under a program other than Medicare FFS
Cost report settlement
Service dates > 3 years
Paid earlier > 10/1/07
Claims where beneficiary is liable for the overpayment
15. RAC Medical Request Limits
16. Inpatient Hospital
17. Other Part B Billers
18. Demonstration Phase Target Areas
19. One-Day Stay Large numbers of inpatient one-day stays - clinically appropriate for an outpatient setting
Focus is on chest pain and back problems
Inappropriate one-day stays linked to incorrect admission status
Medicare rules the attending physician should determine a patients admission status when the patient is admitted to the hospital
20. Improper DRGs 416 Septicemia >17*
217 Wound debridement & skin graft*
468 Extensive OR procedure unrelated to principal dx
124 Circulatory disorders except AMI with cardiac cath & complex dx
475 Respiratory system diagnosis with vent support*
076 Other respiratory systems OR procedure with CC
415 OR procedure for infectious & parasitic disease
082 Respiratory neoplasms
477 Non-Extensive OR procedures unrelated to the principal dx
397 Coagulation disorders*
148 Major small & large bowel procedures with CC
* Most DRG changes by the RAC
21. Improper DRG Example
22. Septicemia vs. UTI
23. Another Improper DRG Example Respiratory system diagnosis with vent support (DRG 475)
Principal diagnosis on claim did not match the principal diagnosis in the medical record.
Principal diagnosis definition - the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.
DRG 475 (Respiratory system diagnoses) and DRG 468 (extensive OR procedures unrelated to the principal diagnosis) are the most common DRGs with this problem.
Due to incorrect coding.
24. Debridement Procedure code of 86.22 (Excisional debridement of wound, infection or burn).
Documentation issues: The physician writes debridement was performed via minor scissoring.
Coding Clinic 1991 Q3 states Unless the attending physician documents in the medical record that an excisional debridement was performed (definite cutting away of tissue, not the minor scissors removal of loose fragments), debridement of the skin should be coded to 86.26, non excisional debridement of skin
Any debridement of the skin that does not meet the criteria noted above or is described in the medical record as debridement and no other information is available should be coded as 86.26. (ligation of dermal appendage).
25. Inpatient Procedures
26. Incorrect Discharge Status A patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter.
The discharge status code occasionally affects DRG and reimbursement.
Hospitals are not adequately updating Medicare on the discharge status of patients. As a result, Medicare often pays two separate locations for the treatment of a single patient.
CMS developed a list of transfer DRGs under the Post-Acute Care Transfer (PACT) policy. PACT requires hospitals to report accurate discharge disposition codes even when a patient's disposition changes after discharge.
RAC will catch claims that overlap with another post-acute care claim.
27. Example of Incorrect Discharge Status
28. Three-day length of stay transferred to a SNF Inpatient patients that appear to be held in the hospital for three days when the care could have been provided in an outpatient setting.
When a patient is admitted as an inpatient for a minimum of three days, the patients 100 days of covered SNF benefits are reactivated.
RACs will focus on the SNF patients with diagnoses indicating back problems that could be treated as outpatients, rather than inpatients.
29. Inpatient Rehab Inpatient rehabilitation must meet medical necessity criteria (HCFA Ruling 85-2 and Medicare Benefit Policy Manual Section 110).
Inpatient rehabilitation patients must have a condition that requires medical rehabilitation at a hospital level. Including the following:
Intensive rehabilitation (at least three hours per day)
Require care by physician
Require 24-hour care by registered nurse
Require a coordinated care program
Expected to achieve significant improvement in a reasonable period of time
Reasonable length of stay
Realistic rehabilitation goals
RAC will determine if inpatient rehab stays meets above criteria.
30. Neulasta Wrong # Units (OP) Neulasta (generic Pegfilgrastim) - used to treat neutropenia (lack of certain white blood cells) caused by receiving cancer chemotherapy.
HCPCS code J2505 (Injection, pegfilgrastim, 6 mg).
CMS noted that many providers billing multiple units of J2505 were consistently billing 6 units per date of service (which equals 36 MG of Neulasta given).
HCPCS code J2505 is usually administered via a pre-filled syringe of 0.6 ML, which is equivalent to 6 MG of Pegfilgrastim.
Providers should ensure they are billing for the number of multiples of 6 MG administered rather than the number of MG administered.
31. Incorrect Units Outpatient Hospital Speech Therapy
CPT codes 92506-92526 .
Speech therapists often evaluate the patient for varying amounts of time, depending on the condition of the patient.
The CPT definition of the speech therapy codes do not include time increments.
Speech therapy services are often reported more than once per encounter (per 15 minute increments).
RAC found the error based on CPT code and units. The patients medical record is not reviewed. (Automated Review, Medically Unnecessary Services).
32. # of Units Medical Necessity Blood transfusions
CPT 36430 (Transfusion, blood or blood components).
Often billed as 1 unit per pint rather than 1 unit per transfusion session.
Blood transfusion 36430 should be charged only ONCE per day, regardless of the number of units given.
33. Use with a Modifier -25, same day as a procedure.
Utilized within the surgical global period.
New versus established.
Levels of Service may or may not be included (currently under review by AMA and the physician community). Will notify physician community prior to allowing RACs to review.
34. Get Ready for RAC Today Develop RAC Steering Committee
Assess Current Risk
Develop Processes for Managing the RAC Roll-Out
Develop RAC Tracking Tool
35. Development of RAC Steering Committee HIM, Compliance, Internal Audit, Finance. Case Management, Coding, CDM, Nursing / Medical Staff
Toolkit Team Baseline statistics to assess risk, determine future tracking and reporting tools including dashboards
Logistics Work Team development of operating model
Education / Training and Communication
Process Improvement Work Team
External Relations Work Team Lessons learned, collaborative opportunities, etc.
36. RAC Risk Assessment based on Benchmarks
37. Audits Tools
38. RAC Audits based on those areas identified as Potential Risks
39. Process Improvement Initiatives
40. Education is Key
41. Developing the Operating Model How and where will requests be tracked?
Who will be responsible for tracking the requests?
How will the medical records be assembled and who will be responsible?
How will utilization review examine the cases and how will risk be assessed?
How will withhold dollars be tracked?
Who will analyze the RAC denials and manage the appeals process?
42. Team RAC Front End Processes
43. Team RAC Risk Assessments
44. Team RAC Appeals / FTE Allocation
45. Timeline Receipt of Initial Request
46. Timeline - Receipt of Demand Letter to Appeal
47. Levels of Appeal
48. Develop Tool to Track RAC Process Initial Chart Request
RAC Due Dates (Chart requests / Appeals, etc.)
Patient Demographic Information including MRN & Acct #
DRG or APC
Total Charges, Receipts and Take backs
Automated / Complex, RAC Findings
Alerts on Impending Deadlines
Ability to Build Risk Timeframes
Ability to Easily Monitor Backlog
49. What does the tool need to do? Monitor outcomes
Predict trends based on current claims volume
Calculate financial impact
Indicate percentage appealed and overturned
Reveal root causes of take backs; i.e., documentation, coding, etc.
Help prevent future cases through education and training
50. Review Vendor Functionality
51. Additional things to think about
. Special adjustment code for tracking and trending take backs
If inpatient denial, rebill Part B outpatient ancillary only
If inpatient denial, monitor and process supplemental refund
If outpatient denial / OBS, monitor for ancillary CPTs that are allowed
Prepare letter to send to patient if denials as there will be impact to the patient
Process to track and bill for chart copies and postage
Preparation of scripts for Customer Service
Time to Rac and Roll!