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READY OR NOT: RAC Here We Come. Donna D. Wilson, RHIA, CCS, CCDS Senior Director/Compliance Concepts PHIMA-May 9, 2011. How many hats do coders wear?. How many hats do coders wear?. Coder - assigning the most accurate code . Finance – assigning the most accurate DRG .

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Ready or not rac here we come


Donna D. Wilson, RHIA, CCS, CCDS

Senior Director/Compliance Concepts

PHIMA-May 9, 2011

PHIMA Annual Meeting

How many hats do coders wear
How many hats do coders wear?

CCI-Compliance Concepts, Inc.

How many hats do coders wear1
How many hats do coders wear?

  • Coder- assigning the most accurate code.

  • Finance–assigning the most accurate DRG.

  • Medical Record Clerk –pulling and reviewing records prior to audits.

  • IT- abstracting cases/RAC database.

  • Core Measures- educating on coding guidelines.

  • Case Manager- reviewing orders/ clinical indications.

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How many hats do coders wear2
How many hats do coders wear?

  • Medical Necessity- identifying correct diagnosis.

  • Clinician- reviewing labs/radiology/operative reports.

  • Discharge Planner-investigating correct discharge disposition status.

  • Educator-conducting roundtables.

  • Auditor- preparing for RAC Audits.

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  • Define the current governmental audits.

  • Review the record requests and limits.

  • Walk through the RAC discussion period and appeal deadlines.

  • Managing the audit process.

  • Describe various tools to assist in the audit.

  • Discuss appeal writing and discussions.

PHIMA Annual Meeting 2010

Governmental audits

  • Medicare RAC

  • Medicaid RAC

  • MIC

  • MAC

  • CERT


  • HEAT

  • OIG

PHIMA Annual Meeting 2010

Medicare rac

Medicare RAC




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Who are the r a c s
Who are the RACs?




Detect and correct pastimproper payments to allow CMS, Carriers, FIs, and MACs to implement actions that will prevent future improper payments.

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Rac contacts at cms
RAC Contacts at CMS:

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Who will be affected by the racs
Who will be affected by the RACs?

Any provider who bills fee-for-service claims will be subject to review by the RACs.

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Ready or not rac here we come



Manual review:

Suspected error

Medical record needed

55 days to reply

Site of service issue

Proper documentation

Electronic claim review:

  • Duplicate claims

  • Same patient

  • Same date of service

  • Duplicate payment

  • RAC withdrawal

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Claims excluded from a rac audit
Claims Excluded from a RAC Audit:

Claims that have already been reviewed by another Medicare contractor.

Claims involved in a potential fraud investigation.

Self-disclosed claims-provider discovers an error.

Claims for hospice and home health.

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Self disclosure quote
Self-Disclosure Quote:

“If you are a compliance officer and your organization never made a disclosure of an overpayment, know that your compliance program is not working as effectively as it should be,” Sheehan said in an interview and in a July 14, 2010 webinar sponsored by the New York State Office of Medicaid Inspector General (OMIG).”

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Current coding issues inpatient
Current Coding Issues -Inpatient:

  • Sequencing of Principal Diagnosis.

  • Selection of a CC or a MCC.

  • Excisional Debridement.

  • Hepatic Encephalopathy.

  • Sepsis.

  • Transbronchial lung biopsies.

    *Not a complete listing- of issues -visit your RAC website for a complete listing*

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Current coding issues outpatient
Current Coding Issues- Outpatient

Blood Transfusions.



Once in a Lifetime Procedures.


Pediatric codes exceeding age parameters.

Untimed Codes.

*Not a complete listing- of issues -visit your RAC website for a complete listing*

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Dcs denying therapy untimed codes
DCS Denying Therapy Untimed Codes

On June 17, 2010: DCS posted this issue: “ a potential vulnerability may exist if certain codes are billed for more than one unit. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner.”

CMS Pub 100-04, Ch. 5, 20.2

CMS Pub 100-04, Transmittal 1019,dated 3,2006, pgs, 7-11: (now incorporated in the Medicare Claims Processing Manual).

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Dcs denying therapy untimed codes1
DCS Denying Therapy Untimed Codes

There is no publication in any CMS transmittal against billing two separate & distinct untimed codes.

For example, a speech therapy (ST) evaluation on the same day as a physical therapy (PT) evaluation.

NCCI edits do not prohibit billing these codes together.

DCS may be sending you denials-so please review .

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Current medical necessity focus
Current Medical Necessity Focus:

  • Degenerative nervous system disorders .

  • Transient ischemia.

  • Chronic obstructive pulmonary disease.

  • Perc. CV proc. w/Non-DES.

  • Heart failure & shock.

  • Atherosclerosis.

  • Cardiac arrhythmia.

  • Syncope & collapse.

  • Chest pain.

  • Esophagitis, GI & digest. disorders.

  • Medical back.

  • Renal failure.

  • Red blood cell disorders.

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Short hospital stays
Short hospital stays

  • George Mills, Dir. Provider Compliance Group in CMS: “ Defined short hospital stays as 4 days or less.

  • Account for 26% of the entire Medicare fee-for-service error rate.”

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Current medical necessity focus patient status
Current Medical Necessity Focus- Patient Status:

Inpatient Admissions without a Physician's Inpatient Admit Order Description.

Admissions to the inpatient setting require a physician's order in order to qualify and be paid as an inpatient stay.

Provider Type Affected:   Inpatient Hospital

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Patient status
Patient Status:

  • Admit to a location is unclear from a medical necessity standpoint .

  • Is the location an OBS unit or an area to support an inpatient level of care?

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Ticket to the hospital
Ticket to the Hospital:

  • Must accompany each patient to the hospital.

  • Fax with all pre-registration material.

  • Necessary to prevent future RAC denials!

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Ticket to the hospital1

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Rac risks
RAC Risks:

  • Keep abreast of all new issues posted by your RAC.

  • Perform pre-bill audits on designated areas:

  • DRGs

  • Discharge Disposition Codes

  • Units of Service

  • Outpatient coding

  • Medical Necessity

  • Patient Status.

  • Educate applicable staff.

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Coding monitoring risk
Coding Monitoring Risk:

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Medical necessity risk
Medical Necessity Risk:

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Rac deadlines

RAC Deadlines

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Review rac deadlines
Review RAC deadlines

Record requests and limits.

RAC discussion period.

Demand letters/Remittance Advice.

Appeal deadlines.

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Record requests
Record Requests

  • Process record request timely.

  • Review each record for complete content.

  • Mail certified mail return receipt.

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Summary of medical record limits
Summary of Medical Record Limits

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Summary of medical record limits1
Summary of Medical Record Limits:

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Cms rac faq

  • Does the RAC limit on medical records apply per individual National Provider Identifier (NPI) or per group NPI?

  • The medical record limit is linked to the billing NPI number. If your practice is enrolled with Medicare and submits claims for all your practice’s physicians under its group NPI, then the RAC medical record limit is linked to your group NPI. 

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Summary of medical record limits2
Summary of Medical Record Limits:

Other Part B Billers (DME, Lab, Outpatient hospitals)

  • 1% of the average monthly Medicare services (max 200) per NPI per 45 days.

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Review results letter
Review Results Letter:

  • First written correspondence received.

  • Entitled “Review Results Letter-Findings.”

  • If you disagree, contact RAC auditor ASAP.

  • Contact Information for RAC Auditor is supplied on the letter.

  • Detailed information of the denial.

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Demand letter
Demand Letter:

  • Second written correspondence from RAC.

  • No title-the middle of the letter will have the name and address for your FI.

  • Date of demand letter should correspond with the denial date on your remit.

  • Monitor all N432/N469 (RAC denial codes).

  • Detailed explanation of the denial.

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Demand letter1
Demand Letter:

Explains 15 day rebuttal Process.

Outlines Repayment plan options.

Discusses Recoupment process.

Mandates that appeal must be filed within 30 days of the date of the latter to avoid a recoupment.

Next steps in the appeal process.

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Be prepared and watch deadlines
Be prepared and watch deadlines:

  • Master effective appeal letter writing skills.

  • Seek outside assistance.

  • Engage other experts in the organization.

  • Expedite RAC Discussions.

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Medicaid rac

Medicaid RAC

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What is the medicaid rac
What is the Medicaid RAC?

  • The Patient Protection & Affordable Care Act of 2010 (ACA) requires by December 31, 2010 each state Medicaid program contract with one or more RACs to identify underpayments & overpayments.

  • Each state will have flexibility in the design of the Medicaid RAC program requirements.

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Provisions to the proposed rule
Provisions to the Proposed Rule:

  • Deadline extended to April 1, 2011.

  • Contingency fees are capped at 12.5%.

  • Supplemental approach to the Medicaid program integrity (MIC).

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Medicaid rac1
Medicaid RAC

  • Must have an “adequate appeals process” for hospitals to challenge adverse Medicaid RAC determinations.

  • States may use their current Medicaid appeals process or develop a separate appeals process-pending CMS approval.

  • Employ trained medical professionals to review Medicaid RAC claims.

  • Unlike the Medicare RAC program, states are NOT required to pay Medicaid RAC on a contingency fee basis for identifying underpayments.

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Potential savings medicaid rac
Potential savings-Medicaid RAC:

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Practice appeal writing

Practice Appeal Writing



Medical Necessity

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Practice appeal writing1
Practice appeal writing:

  • Coding

  • Medical Necessity

  • Automated

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Defend your code assignments
Defend your code assignments:

  • Apply correct coding guidance for each case based on the discharge date of the patient.

    Acceptable advice:

  • AHA Coding Clinic for ICD-9-CM.

  • AHA Coding clinic for HCPCS.

  • Unacceptable advice:

  • Faye Brown’s Coding Handbook.

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Ready or not rac here we come



Integrity Contractor

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Who are the m i c s
Who are the MICs?




  • Deficit Reduction Act of 2005 to combat fraud and abuse in the Medicaid federal entitlement program.

  • Identify and recover overpayments.

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Mic responsibilities
MIC Responsibilities:

Identify overpayments.

Audit provider claims.

Review of provider actions to determine whether fraud or abuse has occurred or may have occurred.

Educate state or local employees involved in Medicaid administration, and others, with respect to payment integrity and quality of care.

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Mics are successful
MICs are Successful:

  • Identified over $18.6 billion in improper payments in 2008.

  • Beat out Medicare at $10.4 billion and Medicare Advantage at $6.8 billion.

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Current mic issues under review
Current MIC Issues Under Review:

Duplicate claims.

Outpatient claims with a date of service that overlaps an inpatient date of service.

Services provided after the death of a beneficiary.

Unbundling of services. 

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Differences between mic rac
Differences between MIC & RAC:

  • MIC= No record limits.

  • Look-backs based on individual state.

  • Number of days to mail records is based on state rules (15 days usually).

  • No reimbursement for copying and mailing medical records.

  • RAC= Record limits set by NPI number.

  • Look-back period = 3 years.

  • 45 days to mail records (+10 days mailing).

  • RACs reimburse 12 cents/ page for hospital records.

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Differences between mic rac1
Differences between MIC & RAC:

  • MIC= Not paid on a contingency fees, paid through a fee-for-service model. Auditors will be eligible for bonuses based on their performance.

  • May come on-site to do reviews.

  • No rules for MICs.

  • RAC = Paid on a contingency fee.

  • No on-site reviews.

  • Set rules for RAC program.

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Mic provider breakdown
MIC Provider Breakdown:

  • Of the 500 audits currently under review, the provider breakdown includes: 

  • 44 % on hospitals

  • 29 % on long term care facilities

  • 21 % on pharmacies

  • 6 % on other provider types.

  • CMS Open Door Forum

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Mic targets
MIC Targets:

  • Patient discharged dead or alive.

  • Inpatient at time of ambulatory service.

  • Hysterectomy on males.

  • Debridement requiring actual cutting.

  • Heart failure and shock-InterQual criteria reviewed.

  • Ambulatory surgery with no complications to justify inpatient stay.

  • DRG assignment.

  • Observation beds.

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Ready or not rac here we come





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Who are the m a c s
Who are the MACs?




  • Section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).

  • Replaces current claims payment contractors - fiscal intermediaries and carriers - with new contract entities called Medicare Administrative Contractors (MACs).

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Mac responsibilities
MAC Responsibilities:

A/B MACs perform Medicare functions currently administered by fiscal intermediaries (FIs) and carriers.

Allows greater integration of Medicare Part A and Part B claims.

Improves efficiency and accountability in program administration.

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Mac awards
MAC Awards:

  • Nineteen (19) A/B MACs encompassing the majority of Part A/B claims.

  • Four (4) speciality MACs-DME supplier reviews.

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Ready or not rac here we come


Comprehensive Error Rate Testing

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Ready or not rac here we come

  • Selects randomly a sample of approximately 100,000 claims submitted to Carriers, FIs, and MACs during each reporting period.

  • Requests medical records from the health care providers that submitted the claims in the sample.

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Ready or not rac here we come

Review claims in the sample and the associated medical records for compliance with Medicare coverage, coding, and billing rules.

Assign errors to the claims, if applicable.

CERT program cannot, label a claim fraudulent, since they use random sampling.

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Cert medical record requests
CERT Medical Record Requests:

If the provider failed to respond to the initial request after 30 days, the CERT Contractor sent up to three subsequent letters in addition to follow-up phone calls to the provider.

If no documentation was received from the provider once 75 days had passed since the initial request, the CERT Contractor considered the case to be a no documentation claim and counted it as an error.

The CERT Contractor considered any documentation received after the 75th day ―late documentation.

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Five categories of error under cert
Five categories of error under CERT

No documentation.

Insufficient documentation.

Medically unnecessary service.

Incorrect coding.

Other—Represents claims that do not fit into any of the other categories (e.g. service not rendered, duplicate payment error, not covered or unallowable service).

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Improvement in cert program
Improvement in CERT program:

  • May 31, 2009 - Based on CMS policy, during the course of a complex medical review, a claim must be denied if the signature on the medical record is absent or illegible.

  • Through their audit, OIG found that CMS contractors were not uniformly applying this policy. Thus, CMS provided guidance to the CERT contractor that claims should be counted as an error if the CERT reviewer could not identify the author of the medical record entry.

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Ready or not rac here we come


Zone Program Integrity Contractor

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Who are the z p i c s
Who are the ZPICs?





Formally known as the Program Safeguard Contractors (PSC).

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Zpics analysis of data should
ZPICs Analysis of Data should:

Identify potential errors that may be the greatest risk (i.e.: covered vs. non-covered services).

Establish baseline data which will enable the contractor to find unusual trends.

Help identify where there may be a need for a new LCD (Local Coverage Determination).

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Zpics analysis of data should1
ZPICs Analysis of Data should:

  • Identify high volume or high cost services that are being widely overutilized.

  • Identify possible fraud investigations of program areas and/or specific providers.

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Zpics responsibilities
ZPICs Responsibilities

  • Obtain data for all beneficiaries for whom the AC(s) or MAC(s) paid the claims.

  • Required to store at a minimum the most recent 36 months worth of data (including Part A, Part B, and DME) for the jurisdiction defined in their task order.

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Be aware of the zpics
Be aware of the ZPICs

  • Hired indirectly (or in connection with other CMS affiliated contractors) by CMS. (For instance, AdvanceMed Corporation was awarded a $107,957,737.00 five-year contract for Zone 5=which is the ZPIC for NC & SC.)

  • Vitally important that providers facing ZPIC audits immediately and effectively address targeted audit issues.

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Zpics appeals
ZPICs Appeals

To appeal a claim reviewed by a ZPIC, it forwards the records to the CMS affiliated contractor (typically a MAC) so that it can handle the appeal.

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Ready or not rac here we come


Health Care Fraud Prevention and Enforcement Action Team

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What is a h e a t audit
What is a HEAT audit?

Health Care Fraud Prevention




Began in May 2009, Dept. of Justice and HHS formed this team to fight Medicare Fraud.

It has become a Cabinet-level priority for both DOJ and HHS.

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Heat responsibilities
HEAT Responsibilities

  • To prevent fraud and abuse in the Medicare and Medicaid programs by busting fraud perpetrators who are abusing the system and costing billions of dollars.

  • To reduce health care costs and improve the quality of care by eliminating perpetrators who are preying on Medicare and Medicaid beneficiaries.

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Heat responsibilities1
HEAT Responsibilities

To highlight best practices by providers who are dedicated to ending waste, fraud and abuse in Medicare.

To build upon existing partnerships that already exist between the DOJ & HHS to reduce fraud and recover taxpayer dollars.

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Heat action july 16 2010
HEAT Action July 16, 2010

“ Ninety-four (94) people have been charged for their alleged participation in schemes to collectively submit more than $251 million in false claims to the Medicare program in the continuing operation of the Medicare Fraud Strike Force in Miami; Baton Rouge, La.; Brooklyn, N.Y.; Detroit and Houston, announced Attorney General Eric Holder, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius, FBI Director Robert Mueller and Daniel R. Levinson, Inspector General of HHS.”

HEAT team uncovered.

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Ready or not rac here we come


Office of Inspector General

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Ready or not rac here we come

RACs are NOT responsible for reviewing claims for fraudulent activity.

RACs are responsible for referring to CMS any potential fraud identified through the RAC audits. For example, the OIG may be notified of potential fraud identified by the RAC.

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Oig work plan 2011 overvi ew

  • “The Office of the Inspector General will make the most of its proposed $272 million budget for 2011 to expand its activities in support of the joint HHS - DOJ, HEAT”-General Daniel Levinson.

  • Expanding OIG-DOJ Medicare Fraud Strike Forces to thirteen (13 new locations).”

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Oig initiatives 2011
OIG Initiatives 2011:

  • Readmissions


  • Brachytherapy

  • Diagnostic Radiology in ED

  • Replacement of Medical Devices

  • Observation during an outpatient visit

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Oig initiatives 20111
OIG Initiatives 2011:

  • Clinical Social Workers

  • Error-Prone Providers/CERT

  • Date of Death

  • First Level of Appeal/ALJ

  • ZPICs

  • Medicare Benefit Integrity

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Oig initiatives 20112
OIG Initiatives 2011:

  • RACs

  • Medicare Advantage Plans

  • Medicaid Integrity Contractors

  • Medicaid Managed Care

  • Corporate Integrity Agreements

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Manage the audit


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Manage the audit process
Manage the Audit Process

Size of the organization

High performing staff members

Management Staff


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Workflow processes
Workflow Processes

Decide upon a Leader/Czar.

Denote an Location = lockbox or address.

Scan all correspondence into shared drive and into a database/spreadsheet.

Stamp the date received on all correspondence.

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Workflow processes1
Workflow Processes

Notify HIM immediately when the letter has been placed on shared drive and/or into the database.

Consider designating a high-performing clerk into the HIM clerk.

Coordinate with the file clerk and Release of Information (ROI) clerk to process record requests quickly.

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Staffing and budgeting
Staffing and Budgeting

Review your current staffing-do you have enough staff to handle the requests?

Work with your Release of Information (ROI) company to discuss the volume of requests.

Budget for increased supplies, staffing, resources, consultants, legal fees, etc.

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Self assessment
Self Assessment

  • Self test your coding staff yearly.

    1) Basic Anatomy

    2) Coding conventions

    3) Case studies/vignettes

    4 AHIMA CCS and/or CCS-P books.

  • Discuss results with each coder.

  • Educate staff on areas of weakness.

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Educate physicians and other providers
Educate Physicians and other providers

  • Develop testing modules for physicians.

  • Include within annual assessments.

  • Consider simple documentation tips.

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Five best practice debridement documentation components
Five best practice debridement documentation components

Technique- (surgically excised, debrided, cut).


Nature of tissue removed.

Appearance and size of wound.

Depth of debridement.

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Wound debridement question
Wound Debridement Question

How many best practice components are necessary to assign an appropriate Wound Debridement code?

1) One

2) Three

3) Five

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Wound debridement answer
Wound Debridement - Answer

The correct answer is #3 = FIVE.

The 5 Best Practice Components needed to document debridement include:

1) Technique.

2) Instrument.

3) Nature of tissue removed.

4) Appearance and size of wound.

5) Depth of debridement.

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Utilize tools

Utilize Tools

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Tools to assist in audits
Tools to assist in audits

  • Excel spreadsheets

  • Internal databases

  • External databases

  • AHIMA RAC toolkit and books



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Tracking rac activity
Tracking RAC activity

  • Track all correspondence (approvals anddenials).

  • Communicate with Hospital Association.

  • Develop a database or an excel spreadsheet.

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Utilize free tools
Utilize free tools

  • AHIMA RAC toolkit.

  • CMS Open Door Forums.

  • Hospital Association.

  • PEPPER reports.

  • CERT reports.

  • OIG annual reports.

  • Network with your peers.

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Ahima rac toolkit

Sub-team of the Clinical Terminology and Classification Practice Council developed this toolkit to assist you in preparing for the program.

Experts from across the country gathered to discuss key components necessary for an effective RAC toolkit.

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Ahima rac toolkit authors

Jill S. Clark, MBA, RHIA

Gail Garrett, RHIT

Sarah Hurst- student

Linda A. Hyde, RHIA

Laurie M. Johnson, MS, RHIA, CPC-H

Krystal M. Lloyd, RHIA, CCS

Anita Majerowicz, MS, RHIA

Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA

Donna Wilson, RHIA, CCS,CCDS

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Toolkit includes the following it is free

1) Overview of audit process.

2) Preparation checklist.

3) Hierarchy of Authority.

4) Sample Policy and Procedure.

5) Sample RAC Coordinator Job description.

6) Education materials.

7) Sample Appeal Letters.

8) Appeal Submission Checklist.

9) Resource links.

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Cms open door forums
CMS Open Door Forums

  • Live dialogue between provider community and CMS & assists providers in understanding program issues.


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Hospital and or medical association
Hospital and/or Medical Association

  • Participate in monthly conference calls with your Hospital Association.

  • Attend face-to-face meetings in order to network with others and hear the questions.

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Pe pp er

  • P=Program for

  • E=Evaluating

  • P=Payment

  • P=Patterns

  • E=Electronic

  • R=Reports

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Pe pp er1

Each hospital will now be compared to other hospitals in three (3) comparison groups:


MAC/FI area


*Hospital data with a numerator or denominator lower than eleven (11) will not be displayed. *

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Pe pp er2

Uncover potential DRG errors.

Reveal MSDRGs that are problematic.

Compare hospital performance.

Educate in areas of need.

Assist in improving documentation.

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Four new coding targets being added to pepper
Four new coding targets being added to PEPPER

Unrelated operating room procedures,

Complications/comorbidities (CCs) and major CCs (MCCs) for surgical DRGs,

Excisional debridement, and

Ventilator support.

CCI-Compliance Concepts, Inc.

Fourteen new medical necessity targets being added to pepper
Fourteen new medical necessity targets being added to PEPPER

  • Transient ischemic attack,

  • Chronic obstructive pulmonary disease,

  • Percutaneous cardiovascular procedure with stent insertion (both drug eluting and non-drug eluting stents),

  • Syncope,

  • Circulatory system diagnoses,

  • Other digestive system disorders,

  • 30-day readmissions to the same hospital.

CCI-Compliance Concepts, Inc.

Fourteen new medical necessity targets being added to pepper1
Fourteen new medical necessity targets being added to PEPPER

Two-day stays for other vascular procedures,

Two-day stays for heart failure and shock,

Two-day stays for cardiac arrhythmia,

Two-day stays for esophagitis/gastroenteritis,

Two-day stays for nutritional/metabolic disorders,

Two-day stays for renal failure, and

One-day stays for chest pain/atherosclerosis (which is a hybrid of the existing one-day stay for chest pain target and a new risk area for atherosclerosis).

CCI-Compliance Concepts, Inc.

Office of inspector general oig workplan
Office of Inspector General (OIG) Workplan

Distributes annual work-plan.

Describes audits and evaluations that are underway or are in the plans to initiate in the Fiscal Year ahead.

Use as a guide in determining areas to monitor coding/documentation patterns.

CCI-Compliance Concepts, Inc.

What is a voluntary disclosure
What is a Voluntary Disclosure

Repayment of monies that have been inappropriately received to Medicare, Medicaid, Tricare Commercial Payers

CCI-Compliance Concepts, Inc.

Three step process
Three Step Process

  • Identification of an issue that resulted in an overpayment

  • An internal review to determine the amount of the overpayment

  • Reporting and repayment

    • DOJ

    • OIG

    • Carrier or Intermediary

CCI-Compliance Concepts, Inc.


Issues that result in Voluntary Disclosures can come from many sources.

  • Routine compliance review

  • Hotline calls

  • Employee complaints

CCI-Compliance Concepts, Inc.

Voluntary disclosure conclusion
Voluntary Disclosure Conclusion

The process may be painful and the result may not be favorable but:

It is fasted, cleaner and cheaper to clean up your own house than having the Government drop by for a three year visit.

CCI-Compliance Concepts, Inc.

Good news
Good news

If your daily practices in coding/billing documentation are excellent, you may never receive correspondence from the government.

CCI-Compliance Concepts, Inc.

Practice oral discussions

Practice Oral Discussions

CCI-Compliance Concepts, Inc.

Role play discussions with governmental auditors
Role play “Discussions” with governmental auditors

  • Have the medical record accessible.

  • Flag pertinent pages of information.

  • Stick with the current issue under review.

  • Be prepared with applicable supporting documentation and guidance.

CCI-Compliance Concepts, Inc.

Contact information

  • Donna D. Wilson, RHIA,CCS,CCDS

  • Compliance Concepts, Inc.


  • 843-345-4653


CCI-Compliance Concepts, Inc.


  • CMS RAC website:

  • AHIMA RAC toolkit:

  • AHA Coding Clinic for ICD-9-CM:

  • PEPPER Resources:

CCI-Compliance Concepts, Inc.


  • Connolly Healthcare:

  • Open Door Forums:

  • Sharon B. Easterling, MHA, RHIA, CCS /AVP Enterprise RAC Department /Carolinas Healthcare System.

CCI-Compliance Concepts, Inc.



Office of Inspector General (OIG):

OIG Work-plan 2010:

Medicaid PERM

Medicaid Integrity Program

CCI-Compliance Concepts, Inc.


HcPRO, HIM Connection. December 15, 2009.

Medicare Administrative Contractors:

MAC Jurisdictions:


CCI-Compliance Concepts, Inc.


  • HEAT:

  • HEAT Action:

  • Marion, Pat. Compliance Concepts, Inc. Voluntary Disclosures. Physician RAC Summit. Jan 2011.

  • AHA Special Bulletin. November 8, 2010. Medicaid RAC.


CCI-Compliance Concepts, Inc.