RAC Readiness Webinar What’s Going On With the RACS? Have the MACS Slowed Them Down?

1. RAC Readiness WebinarWhat’s Going On With the RACS?Have the MACS Slowed Them Down? Presented by: HomeTown Health October 28, 2009

2. Topics for Today’s Meeting: Connolly RAC Update Problem Areas Identified from the Initial Results of the RAC Readiness Survey CMS Strategy for MACS vs. RACS Dale Gibson’s Observations

3. Connolly RAC Update

4. Email from Amy Reese, CMS From: Reese, Amy (CMS/OFM) [mailto:Amy.Reese@CMS.hhs.gov] Sent: Tuesday, October 20, 2009 8:03 AM To: Kathy Whitmire Subject: RE: HomeTown Health Hi Kathy, We are busy busy here, just trying to finish up with the last of our travel.  There’s nothing much to update at this point.  Connolly is working with the Cahaba for some improperly paid claims in GA (these issues are listed on Connolly’s website), but I don’t believe any demand letters have gone out.  They are still being adjusted by the MAC.  If you have any specific questions, please let me know and I can address them for you. Christine has been out of the office for a bit, and is dealing with a family emergency.  I’ll let her to get in contact with you. Thanks, and hope all is well with you, Amy Reese CMS/OFM/PCG/DRAO 410-786-8627

5. Telephone call from Christine Castelli, Connolly– 10-26-09 Monday Morning call from Christine Castelli – Just returning to the office after 6 months of travel performing Outreach education that was required to be complete before RAC startup. Christine reports that all the claims identified in the automated reviews have been sent to CAHABA and CAHABA is now working with the file to notify the providers through N432 Remark Code. PLEASE NOTE: that the claim line will show a negative number that appears that the money has been taken back; however, upon reconciliation you will find that it has not been taken back. The claims will not be taken back until after the 2nd level of appeal not overturned. She said that providers should see the automated remark code notification on the 835 RA’s by the end of this week. In addition, she emphasized that the complex claim reviews were underway and that this would be where the bulk of the money will be recouped. All providers should be working to audit and identify the claims covered under any of the Medicare target areas and areas identified in the demonstration project. They will be reviewed first.

6. New RAC Rollout Schedule CMS Issues New RAC Roll-out MapRACs may begin auditing hospitals in states where the Centers for Medicare & Medicaid Services and the local RAC have conducted a hospital outreach session and the RAC has a joint operating agreement with the CMS-contracted Medicare Administrative Contractor (MAC) or Fiscal Intermediary (FI) for that state.  RAC audits are limited to those particular http://www.aha.org/aha/issues/RAC/contractors.html

7. NEW FAQ ON CMS Website Q: Will Code N432 appear on the remittance advice for Recovery Audit Contractor (RAC) adjusted claims? A: CMS created code N432 to identify RAC adjusted claims, however CMS believes the code is being superseded in some of the systems by code N469 which is the Section 935 Limitation on Recoupment code. We are working to correct this problem in the system. Providers will receive demand letters for all RAC adjusted claims. These letters will allow providers to keep track of RAC adjustments versus all other claims processing adjustments.

8. What is a Section 935 Limitation on recoupment? Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), which limits CMS's recoupment of overpayments during the Medicare appeals process. The important points of interest for providers are as follows: • For overpayments subject to this limitation on recoupment, Medicare will not begin overpayment collection of debts (or will cease collections that have started) when it receives notice that the provider has requested a Medicare contractor redetermination (first level of appeal) or a reconsideration by a Qualified Independent Contractor (QIC). • As appropriate, Medicare will resume overpayment recoveries with interest if the Medicare overpayment decision is upheld in the appeals process. • If the ALJ level process reverses the Medicare overpayment determination, Medicare will refund both principal and interest collected, and also pay 935 interest on any recouped funds that Medicare took from ongoing Medicare payments. (If a provider has any other outstanding overpayments, Medicare will apply the amount collected first to those overpayments and any excess monies will then be refunded back to the provider.) • Payment of 935 interest is only applicable to overpayments recovered under the limitation on recoupment provisions. Interest is only payable on the principal amount recouped. • Providers must note that when Medicare sends a demand letter notifying a provider of Medicare’s intent to collect an overpayment, the provider may submit a letter of rebuttal that disputes the debt. The rebuttal letter will not necessarily stop Medicare from beginning the process of recouping that debt. Only a provider’s timely and valid request for a redetermination or reconsideration will halt the recoupment.

9. RAC RECOUPMENT Questions from WPS Ask the Contractor Session Q. We have received a couple of letters at this point, but by the time that we received the letters, Medicare had already recouped the money. A. Although it appears on your remittance advice (RA) that the money has already been recouped at the line level, the money is not actually taken from the Net Provider Payment. The N469 remarks code at the claim level is only a notification that this claim is subject to the Limitation on Recoupment, 935 Demand. Once an amount is withheld it will be in the summary section of the RA under the 935 Withholding section.

10. Q. In what segment of the 835 are you seeing the remarks code N469? I am looking at the POB section of the 835, so I’m assuming when it’s a 935 transaction, they are taking the money back at the account level, as acknowledgment, but then at the bottom, they are giving us the money back until we respond to it, or let the actual recoupment occur, is that correct? A. On the 835 electronic RA, you would see the remarks code N469 under the reason code section on the “raw file”, and yes, you are correct on the recoupment notification.

11. Q. Can you explain the sequence of correspondences that I should expect to receive in the event that I receive a 935 letter? Specifically, after we receive the letter and there has been a denial of the service, can you explain what we should expect to see as a provider? With regards to our RA adjustments, claims account receivable letters, etc. can you tie that in? A. Let’s use the example of if your claim was reviewed based on a probe review by our medical review department, you will get your notification from the medical review department first, saying this is what we found not to be payable, and these are the individual cases that we are not allowing full or partial payment. As soon as the claim processes in the system, it will hit the remittance advice and the 935 Limitation on recoupment at the same time. Depending on how you respond to the 935 letter, will depend on what you see next. If you submit a rebuttal, within 15 days you will get notification regarding the rebuttal. If you submit a valid and timely appeal request, you will receive a brief notice stating that we received the valid and timely request, and recoupment has stopped. You will then receive the appeals determination, and your rights as a provider based on the appeal review. Each letter will give some information as to what your next step is. http://www.wpsic.com/medicare/j5macparta/training/on_demand/audio/_files/092809teleconferenceminutes.pdf

12. Problem Areas Identified from the Initial Results of the RAC Readiness Survey

13. RAC Readiness Survey Results (These results are based on the first 18 hospitals to return their surveys.)

14. Top 5 Items Not Started • Assess risks with a pre RAC review conducted by a vendor knowledgeable in CMS coverage and coding regulations and RAC processes. • Review new requests and status of those in process. • Design standard templates for specific types of denials. • Establish Case Management coverage 7 days a week. • Implement preprinted physician order sheets with specific orders for "O/P observation services" or "admit to inpatient status".

15. ASSESSMENT

16. ORGANIZATION/STRUCTURE

17. REQUESTS

18. APPEALS

19. CHARGES

20. COMMUNICATIONS PLAN

21. TRACKING/MONITORING

22. PROCESS IMPROVEMENTS

23. EDUCATION

24. What is CMS Strategy for MACS vs. RACS? RACS in the short term – MAC’s in the Long term

25. Widespread Probe Notification – GA – Part A - Notice to providers of upcoming Widespread Probe Review of DRG 195 Simple Pneumonia & Pleurisy w/o CC/MCC As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of DRG 195 Simple Pneumonia & Pleurisy w/o CC/MCC for Bill Type 11X.  Claims meeting the parameters of this edit will be selected across the provider community.  Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor LCD’S, correct billing and coding).  This will be a full claim review.  The data from this review will assist us in determining our provider’s educational needs.  Once completed, the results of this probe will be posted on our website.  Page last updated: June 22, 2009

26. Widespread Probe Notification – GA – Part A – Notice to providers of upcoming Widespread Probe Review of CPT 64475 and 64476 – Injection, Anesthetic Agent and/or Steroid, Paravertebral Facet Joint or Facet Joint Nerve: Lumbar or Sacral, Single Level, and each additional level for Bill Type 13X As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of CPT 64475 and 64476, Injection, Anesthetic Agent and/or Steroid, Paravertebral Facet Joint or Facet Joint Nerve.  Claims meeting the parameters of this edit will be selected across the provider community.  Once selected, the claims will be reviewed for correct billing of this CPT code.  The data from this review will assist us in determining our provider’s educational needs.  Once completed, the results of this probe will be posted on our website.  Page last updated: June 22, 2009

27. Widespread Probe Notification – GA – Part A – Notice to providers of upcoming Widespread Probe Review of DRG 690 Kidney & Urinary Tract Infections w/o MCC (major complications an comorbidities) for Bill Type 11X As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of DRG 690 Kidney & Urinary Tract Infections w/o MCC for Bill Type 11X.  Claims meeting the parameters of this edit will be selected across the provider community.  The topic code for this review will be 5007Q.  Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor LCDs, correct billing and coding).  This will be a full claim review.  The data from this review will assist us in determining our providers’ educational needs.  Once completed, the results of this probe will be posted on our web site. Page last updated: July 13, 2009

28. Widespread Probe Notification – GA – Part A – Notice to providers of upcoming Widespread Probe Review of CPT 97597 & 97598 for Bill Type 13X As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of CPT 97597 Wound Debridement; Total Wound(s) Surface Area < or= 20 Centimeters for Bill Type 13X and CPT 97598 for Wound Debridement; Total Wound(s) Surface > 20 Centimeters for Bill Type 13X.  The topic for this review will be 5003Q and 5004Q.  Claims meeting the parameters of this edit will be selected across the provider community for Revenue Codes 0510 and 0420.  Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor LCD’S, correct billing and coding).  This will be a line level review.  In addition to reviewing CPT 97597 and 97598, all E/M codes billed on the same date of services as 97597 and 97598 will be reviewed.  The data from this review will assist us in determining our providers’ educational needs. Once completed, the results of this probe will be posted on our web site. Page last updated: July 13, 2009

29. Widespread Probe Notification – GA – Part A – Notice to providers of upcoming Widespread Probe Review of CPT 99291, Critical Care, Evaluation and Management of the Critically Ill or Injured Patient: First 30-74 Minutes, TOB 13X As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of CPT 99291 Critical Care, Evaluation and Management of the critically Ill or Injured Patient; First 30-74 Minutes, TOB 13X.  The topic code for this review will be 5005Q.  Claims meeting the parameters of this edit will be selected across the provider community.  Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor LCDs, correct billing and coding).  This will be a line level review.  The data from this review will assist us in determining our providers’ educational needs. Once completed, the results of this probe will be posted on our website. Page last updated: July 13, 2009

30. Widespread Probe Notification – J10 MAC Part A - Notice to Georgia Providers of Upcoming Widespread Probe Review of DRG 552 Medical Back Problems w/o MCC As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of DRG 552 Medical Back Problems w/o MCC for Bill Type 11X.  The topic for this review will be 5008Q.  Claims meeting the parameters of this edit will be selected across the provider community.  Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor LCD’S, correct billing and coding).  This will be a full claim review.  The data from this review will assist us in determining our provider’s educational needs.  Once completed, the results of this probe will be posted on our web site.  Page last updated: August 31, 2009

31. Widespread Probe Notification - Notice to Providers of Upcoming Widespread Probe Review of CPT 85025 for Bill Type 13X As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of CPT 85025 (CBC w/ differential) for Bill Type 13X.  The topic for this review will be 5169V for Alabama providers, 5010Q for Georgia Providers and 5000T for Tennessee providers.  Claims meeting the parameters of this edit will be selected across the provider community.  Once selected, the claims will be reviewed for the correct physician’s orders and that the correct test was performed and billed.  This will be a line level review.  Errors for the improper billing of CPT 85025 have been identified via the Comprehensive Error Rate Testing (CERT) Program.  Documentation submitted by providers to substantiate billing indicates an order by a physician for a CBC with no mention of differential and the billing indicates a CBC with automated differential.  The Centers for Medicare and Medicaid Services (CMS) has directed the CERT Contractor that all claims must be reviewed in accordance with clinical review judgment that does not override statutory, regulatory, ruling, national coverage decision or local coverage decision provisions.  The data from this review will assist us in determining our providers’ educational needs. Once completed, the results of this probe will be posted on our web site. Page last updated: September 4, 2009

32. Widespread Probe Notification – J10 MAC A – Notice to Providers Regarding the Claim Selection for the Widespread Probe Review of CPT 85025 CBC with differential Cahaba Medical Review experienced a problem with the CBC with diff (CPT 85025) Probe review edit 5169V for AL providers, 5010Q for GA providers and 5000T for TN providers for CBC with diff (CPT 85025).  Many more claims were selected than we intended; therefore, we will be releasing all of the claims selected on September 14, 2009 or September 15, 2009.  We will later turn the edit back on to select the sample claims for the Probe.   We  apologize for any inconvenience this may have caused.  Page last updated: September 18, 2009

33. Widespread Probe Notification – J10 Mac A - Notice to providers of upcoming Widespread Probe Review of HCPCS A0429 Ambulance BLS Emergency Transport for Bill Type 13X As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of HCPCS A0429 Ambulance BLS Emergency Transport for Bill Type 13X.  The topic for this review will be 5171V for Alabama providers, 5012Q for Georgia Providers and 5004T for Tennessee providers.  Claims meeting the parameters of this edit will be selected across the provider community.  Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS’ guidelines, contractor LCD’s, correct billing and coding).  This will be a line level review.  The data from this review will assist us in determining our providers’ educational needs. Once completed, the results of this probe will be posted on our website. Page last updated: September 23, 2009

34. Widespread Probe Notification – J10 Mac A - Notice to providers of upcoming Widespread Probe Review of HCPCS A0428 Ambulance BLS Non-Emergency Transport for Bill Type 13X As a result of data analysis, Cahaba GBA will soon be conducting a widespread review of HCPCS A0428 Ambulance BLS Non-Emergency Transport for Bill Type 13X.  The topic for this review will be 5170 for Alabama providers, 5011Q for Georgia Providers and 5003T for Tennessee providers.  Claims meeting the parameters of this edit will be selected across the provider community.  Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS’ guidelines, contractor LCD’s, correct billing and coding). This will be a line level review.  The data from this review will assist us in determining our providers’ educational needs. Once completed, the results of this probe will be posted on our website. Page last updated: September 28, 2009

35. Dale Gibson’s Observations