RACs Rescinding Records Reviews

November 2nd, 2010

Are the RACs “Sandbagging” Denials?

RACs officially rescinded some reviews recently, even after having completed complex reviews, including the issuance of denial letters to the providers for the claims reviewed. This has occurred in at least two of the four RAC Regions. Some providers now fear that this may be the beginning of a trend whereby the RACs request records, citing “good cause” for a CMS approved issue; subsequently find no evidence of that approved issue; but while reviewing the records, find evidence of a different, not yet approved issue. The fear is that the RAC is “sandbagging” the record, in order to wait for a more “lucrative” cause for denial. While this may seem improper, the guidelines outlined in the RAC Statement of Work (SOW) appear to actually require the RAC to withhold a review results letter if a subsequent review is performed on the same claim.

Denials without Demands

Anyone familiar with the RAC Program knows that once a RAC sends a request to a provider for medical records, the provider has just 45 days to deliver said records to the RAC. (Failure to deliver the records is cause for a complete denial of the claim and subsequent recoupment of the entire reimbursement.) If the provider delivers the records, the RAC then has 60 days to complete their review of the claim and submit a letter to the provider listing their review findings, including a detailed description of the Medicare policy or rule that was violated and a statement as to whether the violation resulted in an improper payment. In the case of an overpayment, the RAC next notifies the appropriate Fiscal Intermediary/Medicare Administrative Contractor (FI/MAC), and the process of recoupment begins.

Medicare uses recoupment to recover the majority of provider overpayments. It is a well-defined process, reducing present and/or future Medicare provider payments, then applying those amounts toward the debt. Providers are notified via a demand letter, indicating the amount that is owed.

In the cases I refer to above, however, no demand letters were sent to the providers. Instead, they received notices that the RAC was “rescinding” either or both the records request and the record review. According to those providers, no further explanations were provided by the RAC or the MAC.

Two Questions

When I was first told of this, I did wonder two things: first, is the RAC allowed to do this; and second, why would the RAC do this? To answer both questions, I decided to review the RAC Statement of Work.

Question #1: Is This Allowed?

The first thing to answer is really about whether the RAC can do multiple reviews on the same claim. If the RAC is not allowed to do so, then this would provide a good answer to the second question.

 If the RAC is only allowed to file a single denial for a claim, but is able to document more than one reason for denial, then the RAC would be smart to use whichever denial would produce the largest fee for the RAC.

However, there is no limitation in the SOW on how many times the RAC may review any claim. In fact, the SOW even provides guidance for what the RAC should do in the case of multiple reviews for a single claim.

In the SOW, under Section F, Activities Following Review, paragraph 3, Communications with Providers about Improper Payment Cases, the RAC is instructed that they may send the provider only one review results per claim. However, later in the same paragraph, there is conflicting instruction. Here is the paragraph, with the conflicting statements in bold:

“The RAC may send the provider only one review results per claim.  For example, a RAC may NOT send the provider a letter on January 10 containing the results of a medical necessity review and send a separate letter on January 20 containing the results of the correct coding review for the same claim.  Instead, the RAC must wait until January 20 to inform the provider of the results of both reviews in the same letter.  It is acceptable to send one notification letter that contains a list of all the claims denied for the same reason (i.e. all claims denied because the wrong number of units were billed for a particular drug).  In situations in which the RAC identifies two different reasons for a denial, a letter should be sent for each reason identified.  For example, if the RAC identified a problem with the coding of respiratory failure and denied several claim(s) because the wrong procedure code and wrong diagnosis codes were billed, the RAC should send two separate letters.  The first letter should list all claims in which an improper payment was identified that contained the wrong procedure code and the second letter should identify those denied because the wrong diagnosis code was billed.”   RAC SOW pp 21, f.

The language is difficult, and we have asked for some clarification from CMS.

Meanwhile, despite the contradictory statements, there are two things we can know for sure.

  1. The RAC is certainly allowed to perform multiple reviews per claim.
  2. If the RAC reviews a claim more than once, the results of reviews for that claim should be sent out at the same time, even if it means delaying the delivery of the earlier review.

Based on these two facts, then, there would seem to be no reason for a RAC to “sandbag” a review, waiting for a later, more profitable denial. If the RAC has two reasons for denial, it is simply instructed to deliver the results at the same time. Therefore, there would be no need to “rescind” a review results letter (according to my interpretation of the above instructions).

So, why rescind?

Question Two: Why would the RAC rescind a Review?

My first thought about why a RAC would rescind a review concerned something I remembered from earlier readings of the SOW – the RAC would not be allowed to review a claim already under review.

In an effort to “minimize the impact on the provider community”, CMS included in the RAC program a system to prevent “overlap” – the RAC Data Warehouse, which holds all the data made available to the RACs by CMS, includes a list of all claims being reviewed by any other government entity (a Medicare contractor, a MAC or law enforcement).

Exclusion: Claims that are Off-Limits for RACs

Claims being reviewed by another entity are considered “excluded” claims, and include those originally denied and later paid on appeal. Exclusions are permanent, but only refer to claims, not providers. Once a claim is excluded, it will never again be available for a RAC to review.  (See SOW, pp. 9, f.)

This would seem, therefore, to be a good reason to rescind a review: the RAC may be adding another review result for the same claim.

If a claim has an MSDRG that has been approved for both DRG Validation and Medical Necessity review, then perhaps this makes sense. However, if a claim’s MSDRG is only approved for DRG Validation, then this may not apply. In such a case, where only one issue is approved for review for that MSDRG, then there may be a more ominous reason for the RAC to rescind the review.

Suppression: Claims and Providers Off-Limits for RACs

Both claims and providers may be under investigation by law enforcement for potential fraud. Any provider and/or claim that is part of an ongoing investigation can be added to the lists in the RAC Data Warehouse, by the appropriate contractor, law enforcement agency or the OIG, thereby marking them as off-limits for RAC review. Unlike exclusions, however, suppressions are temporary. Once removed from the list, they are again fair game for the RAC. (See SOW, pp. 10, f.)

It is conceivable, therefore, that during the process of review, a RAC could be informed that certain claims and/or providers have been “suppressed” and made off-limits. Hence, the RAC might be asked to rescind their reviews for claims from that provider, pending the outcome of any investigation.

Are those the only likely reasons to rescind a review? Not hardly. I heard of at least three other good reasons why RACs would rescind reviews, and none as ominous as the ones above.

Other Reasons to Rescind

We could group these three reasons together and just call them “Mistakes or Misinterpretations” by the RAC. Everyone makes mistakes, and government contractors are certainly no exception to the rule.

CERT Reviews

For example, during the RAC Demonstration Project, the pilot program for the permanent RAC program, there were reviews conducted by the RACs on claims that were also being reviewed by the CERT program. CERT reviews were not being reliably entered into the RAC Data Warehouse, and as a result, there were claims being reviewed by both entities, simultaneously. The process appears to still be “buggy” according to some providers I spoke to this week. CERT reviews are still not being entered correctly into the RAC database.

Critical Access Hospitals

To date, CMS has not determined a final methodology to appropriately calculate recoupment from Critical Access Hospitals (CAHs), due to the complex and different manner in which they are paid, compared to the way that other facilities are paid, under the inpatient prospective payment system (IPPS). So, while reviews can be conducted for CAHs, there can be no review results letters or demand letters, and therefore no recoupment can be done — yet. Nevertheless, there have been some CAHs that were mistakenly receiving review results and demand letters. In those situations, the RAC was required by CMS to rescind the reviews.

The 3-Day Payment Window

Finally, there have been cases where the RAC was required by CMS to rescind their reviews as a result of a newly clarified definition of “other services related to [an] admission” provided to a Medicare beneficiary by a hospital on the date of the inpatient admission, or, during the 3 days immediately preceding the date of admission. The new definition was a result of the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010,” which was signed into law by President Obama on June 25, 2010. CMS issued a memorandum about it and also adopted regulations using the new definition in the IPPS final rule, as of July 30. Since that time, CMS has required the RAC to rescind reviews which did not conform to the new definition. (A complete explanation is available on the CMS website.)

Conclusion

Providers should remain vigilant and always check the work of the RAC. There is no guarantee that what they send to a provider is ultimately correct and conforms to all of CMS’s guidance and regulations.

Rescinding reviews will likely not be a very common occurrence. Nevetheless, as we saw above, there are several good reasons for the RAC to rescind some reviews. I’m sure the ones I’ve listed above are only a few of many.

The good news is that while it might appear at first glance that the RAC is up to something to be fearful about, there really doesn’t seem to be any reason to be anxious. (No more than you already are!)

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Denials for Lack of Physician Orders

September 21st, 2010

Connolly Review Results Letters Arrive Soon After Records Submitted

Word to the wise: Make SURE you have a process in place to check ALL (Medicare, at least) claims that go out your door to be paid, to insure that a clearly worded, appropriate Physician Order exists in the medical record.

If you do NOT insure that the order exists, you are risking the entire reimbursement. And if CMS decides that a pattern of this type of error is in your facility or practice… you are risking FAR more than that reimbursement.

Before I get to the subject of the headline, let me review what else was going on, recently.

Seven New Issues Posted

Last week was a pretty quiet week, which almost no activity by any of the RACs, except for a few additions by Connolly and HDI, on Friday, September 17. Connolly added 20 new DRG Validations, listed in five of six new (yes, really NEW) issues.

1 Duplicate Claims – DMEPOS
2 MSDRG 056: Degenerative Nervous System Disorders with MCC
3 MSDRG 057: Degenerative Nervous System Disorders without MCC
4 MSDRG 249: Percutaneous Cardiovascular Procedure with Non Drug-Eluting Stent without MCC
5 MSDRG 368, 369, 370, 371, 373, 377, 378, 379, 380, 381, 382, 383, 384, 385, 387, 388, 389, 390, 391, 392, 393, 395: Gastrointestinal Disorders
6 MSDRG 820: Lymphoma and Leukemia with Major O.R. Procedure with MCC

HDI added Part A Services delivered during a Hospice period.

1 Hospice Related Services – A

But these “new” issues are not all that happened…

Many Edits Made

Over the past couple of weeks, there have been many edits made to existing posts on all four of the RAC sites.

For example, many posted issues for Region A, DCS, actually removed some states from some of their approved issues. You might want to check the list, especially if you are in Vermont, New Hampshire or Maine. (Vermont was dropped from 14 issues, New Hampshire from 12, and Maine from less than that.)

Acute readmissions have been a recognized target for RACs for some time. There was an interesting edit made to the issue as posted on Region D, HDI’s site. Previously, the issue would deny for same day acute re-admissions for the same DRG with no B4 codes on the second claim. Now, it denies for no B4 or 42 Condition Codes on the second claim.

Another edit made in Region D: under the DRG Validation issue for Nervous System Disorders, MSDRGs 075 and 076 were specifically removed from the approved DRG list. Now, I caution everyone, be careful to not transpose those numbers – in the same issue are the approvals for Medical Necessity and DRG Validation for MSDRGs 057 and 056. I warn you because I myself have more than once looked at the list and been puzzled by it, when I kept thinking that the wrong ones were removed.

Denials for Lack of Physician Order

Despite the lack of activity on the lists themselves, the RACs have been very busy, sending out review results letters and denials. We have seen in Region C the first denials to come thru for a lack of or improper physician orders in a medical record. The types of claims being denied are both inpatient and outpatient. I can give you two examples that happen to be short stays.

An outpatient claim, where the patient wound up staying for 3 days. At some point, the patient’s status was changed to inpatient, which would have been appropriate (I’m told by the provider), except for one thing: in the documentation, there is a Nurse’s note, changing the patient status to inpatient, but there is nothing at all in the record that indicates that a physician ever approved or ordered this change. The claim was therefore denied, and the provider has no chance on appeal, because the physician’s order simply does not exist.

An inpatient claim, a 1-day stay: the patient was admitted to inpatient, even with just an 8-hour stay. I was told that the services were, in fact, inpatient services, and could have survived audit for inpatient status. Well, it could have survived, except for one thing: no physician order appears in the record to admit to patient to anything. Once again, the claim was denied; and again, there is no chance to appeal, since the order simply does not exist in the record.

Want to know the scary thing? Those claims were very easy to deny, they are not “worthy” of appeal, and the provider told me that the number of records requested was very few, compared to the limits that the RAC could ask for. In other words, the RAC knew exactly which records to ask for, and they were right on the money.  It seems like this is the proverbial “Easy Money” for the RAC.

Like I said, “Word…”

Why Did They Wait?

But if this is so easy, then why wasn’t the RAC doing this more, before now? My opinion is that the RACs have been waiting for at least some of the Medical Necessity issues to be released, so that they don’t have to ask for the records again, or so that they can have all their weapons loaded before they begin the battle in earnest. I think it is because the RACs are private companies, who actually care about efficiency. In the private sector, efficiency means more profits, and this makes private sector companies much better at this kind of work than many government agencies, who don’t have to worry about such “bourgeois” concerns as “profits.”

So What’s the “Word”?

Providers need to insure they have a reliable process in place to check documentation for physician orders before any claim is filed.

Which ones should they check? Only the ones they intend to send out the door. The RACs are willing to do this job for just nine percent of the claim (in Connolly’s case, anyway).

A provider, then, should be willing to do this for slightly more than that… say, 100 percent of the claim.

So I guess I’ll say that’s the “Word”: 100%.

That’s what is at stake, and that’s what providers should check.

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How an MCC Became a CC

September 21st, 2010

DCBAWhy AKI was demoted to CC status by CMS

By Robert S. Gold, MD, CEO, DCBA, Inc.

PDF download of this article HERE.

In March 2008, the National Kidney Foundation sent a letter to the National Centers for Health Statistics and asked that the term “acute kidney injury” (AKI) be an optional phrase for assigning ICD-9-CM code 584.9 (i.e., that it was the current terminology for what used to be called “acute renal failure.”) The request was granted.

CDI specialists and coders looked at the definitions published through the Acute Kidney Injury Network and noted the criteria of stages 1, 2 and 3 of AKI. They began to ask physicians to document AKI whenever a patient’s labs or urine output met those criteria. But in so doing we hurt ourselves-and we hurt “acute renal failure.” And it’s a shame. Now, with CMS’ resulting reduction of acute renal failure to CC, it now has no more severity attached to it than a simple urinary tract infection.

Let’s see where we went wrong and where we have to go to get it right.

WHAT AKI WAS

Long ago, in a galaxy far, far away, we had the terms “acute renal insufficiency” and “acute renal failure,” and we had advice as to when each was appropriate terminology to use in order to assign the codes that were designed for those conditions. These codes included 593.9 for renal insufficiency and 584.9 for acute renal failure (notice I didn’t use the term “acute” in the description of 593.9-it was a nonessential modifier then).

In the medical textbooks and within the medical community there was confusion in the terminology. For example, one medical textbook called the disease “renal insufficiency” and talked about “progressive renal failure,” and another textbook had a chapter entitled “renal failure” and spoke of “anemia of renal insufficiency.”

AHA’s Coding Clinic for ICD-9-CM, First Quarter 1993, p. 17, gave us the following definitions as guidance:

Renal insufficiency
It is generally accepted that renal insufficiency (code 593.9, Unspecified disorder of the kidney and ureter) refers to the early stages of renal impairment, determined by mildly abnormal elevated values of serum creatinine or BUN or diminished creatinine clearance. Clinical symptoms or other abnormal laboratory parameters may or may not be present but are usually minimal.
The treatment of renal insufficiency depends to a very large extent on the underlying cause, with much attention given to the possibility of preventing progression to renal failure.

And on p. 18, Coding Clinic states:

Renal failure
Renal failure (code 584, Acute renal failure, code 585, Chronic renal failure, code 586, Renal failure, unspecified) is a progression of renal insufficiency where renal function is further impaired and overt clinical consequences, such as anemia, have developed. In essence, renal insufficiency is more of an abnormal laboratory assessment, while renal failure incorporates both abnormal laboratory and clinical findings.

Back then, we looked for more than dehydration. We looked at more than a minor bump in creatinine. We looked for a sick patient. Sure, there may have been obstruction due to prostate cancer associated with a high creatinine level which returned to normal soon after suprapubic tube insertion.

Yes, there may have been a patient found down for three days at home who came in with depressed mental status and rhabdomyolysis and responded to a couple of liters of IV fluids in a couple of days. And these patients came back, at least measurably, to normal. But they were sick and they had acute renal failure. And if a patient had two days of diarrhea “altered mental status” and responded to a glass of water to return the creatinine level to normal, we were happy with dehydration or prerenal azotemia or acute renal insufficiency-because that’s what is was.

During this time, the renal world recognized the problems with lack of consistency and did some studies of acute decrease in renal function. It came up with mortality rates, rates of need for Renal Replacement Therapy (RRT – or dialysis) and identified three pretty distinct levels of change in creatinine, change in Glomerular Filtration Rate (GFR) and change in urine production. It also identified two levels of long-term outcome: Return of measurable function, or no return of measurable function. They published their results and findings and called the system RIFLE. And all rejoiced.

But there were two issues of massive importance that somehow didn’t get into the subsequent evolution of acute damage to the kidneys. First, all of the studies were done in critical care units on critically ill patients. Certainly there was mortality-but it was not clear whether the mortality came either from the renal damage or from the other conditions that the patients had at the time of death.

It was merely an observation of mortality, regardless of the cause, in patients with measurable changes in renal function. Secondly, and they were very specific about this-RIFLE only applied to intrarenal damage and did NOT apply to prerenal causes or postrenal causes. Basically, they said that the patients who actually had what they believed was acute tubular necrosis or hemorrhage of the kidney or infectious or immune destruction of renal parenchyma counted, and that the patients with elevations of creatinine due to dehydration without ATN or elevations of creatinine due to obstructing bladder cancer did not count.

Several iterations of acute kidney injury studies followed to validate the results and recommendations above and the Acute Kidney Injury Network was formed. Again, all of the studies were done on critically ill patients on critical care units. But this group changed some of the rules. They eliminated GFR change as a valid measure and that was reasonable, especially if one didn’t know what the patient’s creatinine was before the insult and didn’t know if the end result was a decrease in function or not. And other less important issues could impact GFR than the renal destructive condition.

And then they said that their new staging of “AKI” was applicable to prerenal and postrenal causes because, in critically ill patient in critical care units, many had intrarenal damage because of prerenal and postrenal causes. The problem is that all of their patients again were critically ill and on critical care units. They did not look at creatinine change or urine output change in patients who didn’t make it to the ICU.

I think that this overlooked the 80+% of patients who have changes in creatinine or urine output that falls within their established criteria-particularly of Stage 1.

As an aside, let’s take a quick look at the term “injury” as it has pertained to other organs. There was a time that the pulmonology groups spoke of “acute lung injury” and there were a ton of publications talking about “acute lung injury.” What these investigators recognized is that the myriad of diseases that fall into the category of “acute lung injury” included the range of the most mild to the most severe and that the identification of the particular disease was more important than the vague term of “injury.” Thank goodness for that.

Acute lung injury due to viral pneumonia is a totally different animal than acute lung injury from ARDS due to amniotic fluid embolism. And they now continue to clarify “acute respiratory failure” and distinguish it by pathologic change rather than dwelling on a new term that has no specificity for risk. Should the renal world follow this lead? It’s not for me to say.

WHAT AKI IS

So we are left with a term, “acute kidney injury,” that has a myriad of levels of severity, and entering a reimbursement world where classification of failure of an organ-the kidney – is not an MCC at all. It’s the only failure of an organ that is not a major condition. Why? I believe it’s because the proper homework wasn’t done.

Because of the approved definition of 584.9 to include AKI, all levels of AKI were included in the statistics generated through coding and CDI initiatives. And patients with a creatinine bump of 0.3 mg% due to dehydration who were treated with a glass of water were reported with 584.9-and they went home in six hours when they cleared up mentally.

We have met the enemy and they is us (with fond memories to the critters of the Okeefenokee swamp).

Certainly, patients with stages 2 and 3 AKI are pretty darned sick-and I would guess that a significant portion of patients with stage 1 are sick, as well. But it may not be from the renal disease specifically. They do have other organs!

WHAT AKI SHOULD BE

I see a couple of options to fix the problem and I’ve worked with some of the authorities in renal disease medicine on this. The first is to create individual codes for the three stages of AKI (if we’re going to stay with AKI). And with these levels, we could perform some analysis on all patients with the identified stages, not only on patients on ICUs. We could run statistics from ICU patients only, non-ICU patients only, and all patients, just to see if there is an identifiable difference in mortality or in long term damage of renal function between the groups. By examining mortality, the rate of RRT, and cost, we would have a viable way to identify which patients are sick-who has a major disease-and who isn’t.

The second option is to follow the lead of the pulmonologists and dump AKI. From a coding, resource utilization, and CMS perspective, that’s a great option. From the perspective of statistical analysis of risk of mortality, we need the breakdown of “acute renal failure” or “acute kidney injury” to be studied, analyzed, and classified appropriately. This cannot be accomplished by repeating the flawed studies of the past. Let’s open it up to all comers. If the definition of the disease applies to all comers, the studies have to be done on all comers.

In the meantime, CDI specialists and coders who are dealing with the rules as they exist must look at how sick the patient was and how the patient was treated. If the cause of a bump in creatinine is dehydration and the patient’s treatment consists of a bolus of 500 cc of crystalloid in the ED and then regular diet, or consists of IV fluids at a normal rate of 75 – 100 cc/hour with no efforts at real resuscitation of vital signs and perfusion, and if the patient responds rapidly to these treatments, the patient should be considered to have the old acute renal insufficiency and not coded to 584.9 because it was not failure and it did not entail “kidney injury.” If we’re going to use “AKI,” we have to be able to validate injury, reversible or not. There has to be some consequence.

In fact, Mehta and his group of international nephrologists unanimously agreed that the “that application of the diagnostic criteria would be used only after an optimal state of hydration had been achieved.” (Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury, Critical Care, volume 11, issue 2) [Ed. -- or get the full text PDF here.]

Some consultants are now advising their clients to tell the docs to document “acute tubular necrosis” rather than AKI across the board. That’s a very questionable practice and can do nothing but get you into trouble. If the case is one in which the patient probably has measurable injury of the kidneys, after fluid resuscitation, with acute tubular necrosis due to salicylate poisoning or sepsis or shock, sure-call it acute tubular necrosis, because that’s what it likely is. Even severe dehydration with significant hypovolemia can cause ATN-but it should be significant.

Got it?

About the author:

ROBERT S. GOLD, MD, CEO

Dr. Robert S. Gold is co-founder of DCBA, Inc., and has more than 44 years of experience as a physician, medical director and consultant. A graduate of Hahnemann Medical College in Philadelphia, he trained in General Surgery in the U.S. Navy where he spent his professional career as a practicing surgeon. Since leaving the service, he has worked as a consultant in the fields of Managed Care Medicine, Locum Tenens, Home Health, Hospital accreditation and licensure and, most notably over the past ten years, in audit and education regarding documentation, coding and billing accuracy (DCBA) for healthcare services.

Nationally known for his education regarding the clinical orientation of coding in AHIMA teleconferences and at the National Conference for the Society for Clinical Coding, Dr. Gold is a frequent speaker at industry conferences and is widely published.

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Aiming High with Medical Necessity Reviews

August 23rd, 2010

It’s Worse Than You Think

In previous posts, we’ve reported that two RACs have now posted approval to begin reviews of both medical necessity and DRG Validation, for the exact same 29 DRGs.  We have also previously shown that the RAC lists (as posted earlier this year) are skewed toward high-dollar and high-volume claims, to no one’s surprise.

Nevertheless, we have a “new” list, so let’s take a look at this “List of 29,” let’s call it — the first list of MS-DRGs approved for RAC review of medical necessity. Can we learn anything about what the RACs and CMS are thinking?

The answer is YES, we can.  Click here if you just want to jump down to the conclusion…

How Skewed Is This “List of 29″?

Well… not very, but that’s actually worse for providers! Why is it worse? Read on, and it should be come clear…

The first table below begins with some unfortunate insight, when counting the number of CC or MCCs in the List of 29. If you are not too familiar with the MS-DRG system, we recommend reading a PDF made available by CMS on the system.

Briefly, the Medicare Severity-Diagnosis Related Groups (MS-DRGs) are a system of codes that provide up to three levels of severity for a particular condition or diagnosis. A “Base DRG Group” combines all levels of severity into a single category, allowing us to combine the the individual MS-DRGs for reporting. Individual MS-DRGs within a Base DRG Group are differentiated according to the presence of either a complication (CC) or a major complication (MCC), or neither. Some Base DRG Groups, however, happen to have only two codes assigned to them. At the end of the day, all the MS-DRGs are assigned payment rates, based on their relative use of resources and supplies. Simply put, a condition that is accompanied by a major complication (MCC) is more costly to treat, therefore the provider is paid more for that claim. A condition with a complication (CC) is not paid quite as much, and a condition with neither CC nor MCC is paid the least of the three.

Now consider this table and consider what the numbers reveal:

  • 8 or 28%   – the number of MS-DRGs without a CC or MCC
  • 13 or 45%   – the number of MS-DRGs with an MCC
  • 18 or 62%   – the number of MS-DRGs with either a CC or MCC.

For the sake of this article, let’s just assume that all Base DRG Groups include exactly 3 MS-DRGs: one with an MCC, one with a CC, and one without CC or MCC. If that were true, then any randomly selected list would likely have 33% of each kind of MS-DRG. However, if the list of MS-DRGs was selected with a weighting toward the MS-DRGs with an MCC, then there would be a higher percentage of those in the list, and a lesser percentage of the two others. Basically, any list with one type of MS-DRG appearing more than 33% of the time is evidence that selection of the list favored that type of MS-DRG over the others.

In the above table, MS-DRGs with an MCC appear 45% of the time, and therefore is evidence that the list is skewed toward those MS-DRGs with an MCC. So, as mentioned above, we can once again demonstrate that even this new list is skewed toward the higher paying MS-DRGs, particularly the ones with MCCs. Of course, this still comes as no surprise, since the RACs are paid via contingency fees — the more they find, the more they get paid by CMS.

But I’m not done yet.

The size of the “skew” was disappointing, and something else about those numbers just didn’t sit right with me. The “skew” just wasn’t very big. I was expecting more. And why were there so many lower-paying DRGs in the list? “Whassup with that?” as my teenage daughter would say.

Could it be that the list is not really intended to be very skewed? That’s when the pattern became clear to me, and a reason for that pattern also came to mind…

RAC to CMS: “Hey, it’s all good!”

The RACs have obviously been busy, these past months. They were not sitting idly by, waiting for medical necessity to be released. It appears to me quite obvious that they have been running their little data-mining machines in high gear because it seems that they have dredged up plenty of evidence of improper payments due to what will be defined in denials as “a lack of medical necessity.”

Remember, the only thing that matters to a RAC is the documentation, or the lack there of, to clearly demonstrate medical necessity, not the reality of the patient encounter. And to get approval from CMS to pursue an issue across their region, a RAC must gather enough evidence to make a case that there is a problem with said claims.

I kept staring at the list. A pattern became obvious to me. Perhaps the pattern is obvious to you, too, but I’ve neither seen nor heard anyone else mention what this pattern MEANS for providers, and I do think it is important to recognize, to enable more clear thinking about what the RACs and CMS intend to do.

A Pattern Emerges

The table below shows the pattern: six complete DRG Groups, included in the List of 29. That’s 16 DRGs, more than half of the list. And remember, these are high-volume DRGs…

MS-DRGs Base DRG Group Descriptions
684-683-682 Renal failure
551-552 Medical Back Problems
314-315-316 Other Circulatory System Diagnoses
293-292-291 Heart failure & shock
192-191-190 Chronic obstructive pulmonary disease
056-057 Degenerative Nervous System Disorders

What this means is that for these specific diagnoses, CMS and the RACs have evidently found enough evidence to warrant RAC reviews for the medical necessity of these treatments for ALL such claims, not simply the higher paying ones.

Does this mean that CMS actually believes that the patients really did not NEED these treatments? Doubtful.

Or, does this mean that CMS is willing to argue with physicians about the medical necessity of treating these conditions or that they have been misdiagnosed?  Perhaps this is true, for a few cases; but I even find this doubtful, although to read some articles out there, one would think that physicians are preparing to wage war on who-knows-best-how-to-care-for-patients with the RACs’ medical directors. While such battles will inevitably occur, it would seem to me that this is not the kind of evidence that the RACs have already found and used to convince the New Issue Review Board at CMS to approve reviews for all the MS-DRGs in these six Base DRG Groups.

Here is what I think it more likely means: the RACs have found enough evidence to support the assertion that providers are recording neither appropriate documentation nor enough documentation in the medical record to warrant reimbursement for services provided to Medicare beneficiaries in their facilities, and that the problem is so ubiquitous that it bears scrutiny across almost the full spectrum of DRGs. Remember, HDI already has approval for DRG Validation for about 80% of all MS-DRGs.

I’m neither an expert on medical necessity nor on auditing medical records, but I do know how to analyze data and find patterns and meaning in those patterns. To me, this latest list simply nails the issue. This is not about medicine. It’s about money.

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Nothing New Except Medical Necessity

August 23rd, 2010

RAC-LOGO-HDI

HDI Edits Ten Issues to include Reviews of Medical Necessity for 29 DRGs

The Region D RAC, HDI, only took about a week to also garner approval to begin review of medical necessity for 29 DRGs previously approved for DRG Validation, after the Region B RAC, CGI, was approved by CMS to begin medical necessity reviews for the same DRGs, as of August 6, 2010. However, while CGI had to post six (6) new issues to their site, because those DRGs had never appeared on their site before, HDI did not have to post any new issues. Of the existing 746 MSDRGs, HDI had already posted approvals for DRG Validation of over 75% of them, and these 29 did happen to already be among their approved list.

The I’s Have It: CGI and HDI

Now two of the four RACs have approval to review medical necessity, putting 24 states under such review. We do expect that to grow in the next few days, since it took HDI only about a week to catch up to CGI, so we assume Connolly and DCS are not far behind.

Although our previous post provided lists and links to the 29 DRGs, those links and titles were created using the CGI website data. Also, that list was broken into two lists — one for “new” issues, and one for “previous” issues.

Below is a list of the ten “previous” issues that now include some approvals for medical necessity. It was created using the HDI website data, which is slightly different. To see the full detail, as posted by HDI, follow the links:

(Note: to see the details, you will need to login to the eduTrax main site — Registration is still Free.)

# eduTrax version of the HDI Posted Issue Title Originally
Posted
1 MSDRG 034-036, 215, 222-227, 231-236, 242-249, 258-262, 265, 286-287: DRG Validation-Cardiac Procedures 12/16/09
2 MSDRG 052 thru 086, 088 thru 093 and 097 thru 103: DRG Validation-Nervous System Disorders 12/16/09
3 MSDRG 163, 164, 165, 166, 167, 168,175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206, 207, 208: DRG Validation-MDC 04 Respiratory 12/16/09
4 MSDRG 280, 281, 282, 283, 284, 285, 288, 289, 290, 291, 292, 293, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 313, 314, 315, 316: DRG Validation-Cardiovascular Diseases 12/16/09
5 MSDRG 294, 295, 312: DRG Validation-Cardiovascular, Other 01/13/10
6 MSDRG 368 thru 395 and 432 thru 446: DRG Validation-Gastrointestinal Disorders 12/16/09
7 MSDRG 539, 540, 541, 545-558, 564, 565, 566: DRG Validation-Musculoskeletal Disorders 01/13/10
8 MSDRG 637, 638, 639, 640, 641, 642, 643, 644, 645: DRG Validation-Endocrine, Nutritional & Metabolic Disorders 12/16/09
9 MSDRG 682, 683, 684, 685, 686, 687, 688, 689, 690, 695, 696, 697, 698, 699, 700: DRG Validation-Kidney & Urinary Tract Disorders 12/16/09
10 MSDRG 808, 809, 810, 811, 812, 813, 815, 815, 816: DRG Validation-Blood & Immunological Disorders 12/16/09
 

Most Difficult to Track

It is perhaps insignificant but notable that the first two RACs to be approved for medical necessity review also happen to have the two websites that are the most difficult to monitor for changes. Both sites are constructed in a way that requires interaction, and does not provide a simple method of capturing the data on the page, to compare to a future capture of the same page.

New Service Coming

We have resorted to creating our own software application to specifically follow and compare all the pages on these two sites. Shortly, we will announce and offer a for-fee service to notify our clients and subscribers of any changes posted to any of the RAC New Issues pages, including the details screen, in addition to our eduTrax RAC New Issues Tool Suite®.

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Medical Necessity Approved for RAC, New and Old

August 19th, 2010

Newly Approved Medical Necessity Reviews by RACs

CGI Federal, the CMS RAC for Region B posted approvals for review of both Medical Necessity and DRG Validation for some 29 DRGs since last Thursday, August 12, 2010.

Half of the top 20 DRGs nationwide were included. Click here to jump down to the list.

Our subtitle above calls these “Newly Approved,” instead of “New.”  Why did I use that phrase?  Why not just say “new”? Well, because that’s not quite accurate, and it seems that CMS and CGI don’t consider all of them to be “new” issues. Are you surprised that a word like “new” is not well defined?

This little video snippet should help you recall recent public debate about what the word “is” means.

I’ve had “debates” like that, on occasion, and I’ve always wanted to ask the person debating with me, “How many moons are in your night sky?” Of course, some words change definitions over time, or just mean different things to different people. Small words should be easy to define, though, don’t you think?

Anyway, keep this in mind as you read on, because there does not seem to be a consensus in our industry on what the word “new” means.

More about this later…

 

A Valid “New” Concern for Providers

The morning after the “newly approved” medical necessity issues were first posted by CGI, I spoke with the a RAC Team Leader for a hospital system with hospitals in several states. Even though this system has no hospitals in Region B, I know this person as a keen observer of all the RAC activities, and we often talk about the impact of the RACs. “We heard from our state hospital association that Region B would be the first to post some issues for medical necessity, and that it would happen this week,” they told me. “So, this wasn’t really a surprise. But this marks a new phase for the RACs, and we are concerned about what’s on the list.”

50% of Top 20 DRGs Now Approved

A quick analysis of the list proves that provider concerns are quite valid – of the top 20 DRGs for FY2009, 10 made this new list. Therefore, perhaps half of the top 20 DRGs in any facility either are now or soon will be targets of RAC reviews for medical necessity; and remember, they were already likely targets for reviews of physician admission orders, DRG validation, and the coding for principal and secondary diagnoses.

The First “New” DRGs Approved for Medical Necessity

Now, let me explain a small caveat, about the word “new”:  some of the DRGs approved for Medical Necessity are truly “new” issues, as those DRGs have never appeared on the (CGI) list before; while other DRGs were already approved for DRG Validation, but have now been “newly approved” for Medical Necessity review, as well.

So now, here is a list of six (6) issues with nine (9) DRGs never before posted on the CGI website, but now are posted as approved for review of both Medical Necessity and DRG Validation. To see the full detail, as posted by CGI, follow the links:

(Note: to see the details, you will need to login to the eduTrax main site — Registration is still Free.)

There was also one DRG added for the first time, but only approved for DRG Validation:

Ok, but that’s still only nine of the DRGs. Where are the others posted on the site?

Twenty More DRGs with Medical Necessity “Newly Approved”

The other 20 DRGs now approved for Medical Necessity review were all listed previously for DRG Validation in a total of 12 issues, dating back to December, 2009, among the first complex reviews posted by CGI. These 20 DRGs were not listed as “new” issues, but were simply “called out” as approved for Medical Necessity by renaming those previously approved issues.

The 12 issues with some DRGs newly approved for medical necessity review are as follows:

Confused yet?

Why Not List All Those As “New Issues”?

Why indeed!  NOW, with the lists out of the way, let’s finally discuss why I even bring this up, and why it really will matter to providers — at least the ones who are trying to keep up with what the RACs are doing.

“New” Issues Must Be Posted by the RAC

According to the RAC Statement of Work, before a RAC can begin sending out requests for documentation to conduct complex reviews, or even demand letters for automated reviews already completed, the RAC must first win the approval of any audit issues from CMS, and then they must post all those approved issues on a public web site.

Last August, we all began watching those websites ominously take form and grow by leaps and bounds, in some cases, with the addition of more and more “new,” approved issues. We were curious to see the formats that the RACs were using, as each seemed to have their own private format for posting the issues.

Why Not All Use the Same Format?

Because they don’t have to. The RAC Statement of Work actually says NADA about what the format of these websites should be, and how “approved issues” should be “posted” on the sites. Whence, each RAC has their own interpretation of how to “post” their “new,” dare we say “newly minted,” approved issues.

To be sure, Medical Necessity review was never approved by CMS for a RAC before August 6, (now there’s an ominous date for you) and no issue approved for medical necessity review has being posted on any RAC website before August 11. However… now that such approvals have been garnered, and such posts have been made, at least some of said posts have been done in a manner that could be described as… well… obscure.

I call them obscure because some of these posts wind up as simple “edits” instead of “new” line items.

The method that CGI has chosen for posting approvals of Medical Necessity reviews is either of two methods: 

  1. post it as a new issue if the DRG is not already on the list; or
  2. merely change the name or title of the previously approved issue that lists the DRG, to include Medical Necessity review for one or more of the already approved DRGs in that issue.

So, some 20 of the 29 DRGs wound up “sprinkled” within 12 older issues, and simply had their titles “edited” instead of appearing as “new” line items in the list.

Why does this matter? Because the RACs can now post changes to their list of approved issues, without notice. Of course, they didn’t have to notify any of the providers before, but the lists seemed to do that, after a fashion – a form of notifying providers of what’s being reviewed, what to expect from the RACs.

Since the lists first appeared, many of us were thinking that we could watch the RAC websites and see the “new issues” get posted, from week to week; hoping we could simply sort the list (somehow) by date posted, and we’d know if there was anything “new” on the list or not.

“We all” were wrong. It would seem that “new” doesn’t have the same meaning, as we now see with the way a “new” review approach (medical necessity) is embedded in the original posted issue. Keep in mind that there is no reason to think that the other RACs will not adopt this same approach, also. Instead of posting “new” issues for Medical Necessity, they may simply rewrite the descriptions of their “old” issues, just as CGI has done.

Anyway, more “new”…oops… “edited” issues can be expected, any day. They’ll just be harder to track now, because we’ll have to read every issue, every day, to see what changed.

Oh, and by the way, I only see one moon in my night sky — how about you?

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Connolly Adds Nine RAC Approved Issues

August 4th, 2010

RAC-LOGO-CGIThe RAC contracted for the southern and southeastern states, Connolly Healthcare, continues to post new automated issues concerning dose-versus-units-billed, further proving that injections and infusions is a major target for RAC review, and a continuing concern for provider reimbursement, especially for physicians and outpatient settings.

The List

Below are the nine new issues, posted earlier this week. Follow the links to each one, in the eduTrax RAC New Issue Database®, which can be seen with simple free registration at myedutrax.com.

Who’s Getting Stuck?

You’ve billed for it, even been paid for it. But will you get to keep the money? And you can’t take the injection back…

This is like getting an injection with a barbed needle: feels ok going in, but coming back out it hurts like <insert your favorite expletive>.

For both providers and payers, there’s no confusion about one thing: injections and infusions can be tricky to properly bill.

Instruction Available

The eduTrax® site has two excellent courses available for their paid subscribers, and these can also be purchased as downloads or CDs. Short previews are available to give you an idea of their quality and content:

BLUE-PREVIEW-ON-Button Coding Injections and Infusions — reviews the recent changes to injections and infusions codes and offers guidance on correct capture of these services. (3 minute preview)

BLUE-PREVIEW-ON-Button RAC Focus: Injections & Infusions — discusses why, how & where physicians must be involved, and addresses code selection based upon time and service provided. (8 minute preview)

Click here to send us an Email for more information or to place an order.


Still No Medical Necessity Approvals

To date, there are still no issues posted & approved for review of Medical Necessity for any issue.

As usual, we wait…

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Region B RAC Adds Review of Inpatient Admit Orders, 95 DRG Validations

July 25th, 2010

RAC-LOGO-CGIIn the continuing posting of issues, the RAC contracted for the upper midwestern states, CGI Federal, has now joined Connolly Healthcare in its posting of an issue that can possibly recoup all Medicare Part A charges for an inpatient claim, and still not even touch the dreaded issue of Medical Necessity.

The List

Below are the 15 new issues, posted last week. Follow the links to each one, in the eduTrax RAC New Issue Database®, which can be seen with simple free registration at myedutrax.com.

1 Date of Death-DME
2 Inpatient Admissions without a Physician’s Inpatient Admit Order
3 MSDRG 052, 053, 054, 055, 056, 057, 058, 059, 060, 061, 062, 063, 067, 068, 069, 070, 071, 072, 073, 074, 077, 078, 079, 080, 081, 082, 083, 084, 085, 086, 088, 089, 090, 091, 092, 093, 097, 098, 099, 101, 102: DRG Validation for Nervous System Disorders
4 MSDRG 165: DRG Validation for Major Chest Procedures
5 MSDRG 168: DRG Validation for Other Respiratory System O.R. Procedures
6 MSDRG 175, 176, 180, 181, 182, 183, 184, 185, 186, 187, 188, 192, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206: DRG Validation for Respiratory
7 MSDRG 242, 243, 244: DRG Validation for Permanent Cardiac Pacemaker Implant
8 MSDRG 247, 249, 251: DRG Validation for Percutaneous Cardiovascular Procedures
9 MSDRG 326, 327, 328: DRG Validation for Stomach, Esophageal and Duodenal Procedures
10 MSDRG 371, 372, 373: DRG Validation for Major Gastrointestinal Disorders and Peritoneal Infections
11 MSDRG 405, 406, 407: DRG Validation for Pancreas, Liver and Shunt Procedures
12 MSDRG 474, 475, 476: DRG Validation for Amputation for Musculoskeletal System and Connective Tissue Disorders
13 MSDRG 490, 491: DRG Validation for Spinal Fusion
14 MSDRG 533, 534, 537, 538, 562, 563: DRG Validation for Musculoskeletal Fractures
15 Prosthetic Additions When Billed With Initial Or Preparatory Knee Prosthesis

More to Come

We’ll have more to say about the review of Physician orders, soon…

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The Whistleblower Wore a Wire

July 20th, 2010
Pocket-Size Wire Recorder

Equipment Available before passage of the Healthcare Reform Act of 2009

After bringing  a False Claims Act case to the attention of federal agencies, a Florida whistleblower remained working at WellCare Health Plans offices and then even went so far as to wear a hidden wire (probably just like you see on television) during business meetings, helping the Justice Department (DOJ) in an 18-month undercover operation to capture evidence of alleged fraudulent practices by WellCare officers and employees.

All of this has come to light as of June 25, 2010, when a U.S. District Court judge ordered the complaint unsealed. The original complaint is still not available, but the complaint filed on June 21, in the US District Court for the Middle Florida District, is now available.

(Find it here and other documents related to the case here.)

Might we see an episode of Law & Order soon with this kind of a case? I think it’s pretty gutsy to wear a wire for the Feds, but in this case, the pay-off is much more than just “doing the right thing” or even protecting future victims. Whistleblowers get pretty hefty pay-days, with or without a wire. Perhaps the investigators used that pay-day as a carrot? Wear a wire, get more evidence, you get a bigger pay-day?

Wait… A Settlement was Reached?

Three years later, WellCare reportedly announces that it has agreed to a “Preliminary Settlement” with the Department of Justice, Civil Division, to pay $137.5 million to “settle their pending inquiries.” (Notice that there is no mention of any criminal inquiries…) You can see what WellCare filed with the SEC about this, here. (We can’t seem to find any documents from WellCare or the government, yet, about this supposed settlement.)

Evidently, the whistleblower was not invited to the negotiation where a  settlement was reached, and understandably is not keen on the mere $137.5 million settlement that the government has agreed to with WellCare. According to the whistleblower’s attorney, “…the proposed settlement would permit taxpayers to be unfairly disadvantaged by a settlement that pays less than half of what our pleadings suggest was stolen, to say nothing of the requirement of triple damages under the False Claims Act.“  The attorney and his client estimated that WellCare received over $400 million to perhaps as much as $600 million in fraudulent payments, from a combination of Medicaid and Medicare programs.

Since whistleblowers get 15-25% of the total penalties and damages paid by the offending party, it’s pretty easy to see why this whistleblower is upset — he could be missing out on 15-25% of perhaps as much as $800 million.

The $137.5 million, however, is still only “preliminary” and must be approved in court. We’ve searched the web and there are yet no announcements by the DOJ or any of its Civil Divisions, nor by the OIG or the FBI, related to this settlement. One has to wonder, how did they arrive at this number, which is so much smaller than the alleged frauds? Oh, and, what about penalties and damages? Aren’t those supposed to be added on?

Even if the whistleblower’s figures are inflated, there still appears to be significant fraud. Did the FBI not find much then?

Where’s the beef?

According to several news reports, the DOJ amassed over 1,000 hours of audio and video evidence of alleged fraudulent conduct by WellCare. The whole investigation took almost four years, and included a raid by over 200 federal agents from the FBI, DOJ and the OIG, on the WellCare Tampa headquarters, where they seized many computers and files.

In the complaint, the whistleblower alleges that WellCare purposefully and knowingly over-billed the seven states that it contracted with as a Medicaid HMO. It appears that WellCare used accounting “tricks” to move money around to inflate costs, thereby avoiding having to pay back monies to the state Medicaid programs.

One of the most distrubing allegations concerns WellCare’s apparent complete lack of compassion and utter arrogance in handling care for a large number of newborn babies. One of the examples cited by the whistleblower involved not only unlawfully denying care to 475 newborns for the purpose of eliminating the costs of caring for them, but then rewarding the staff who executed those denials (and perpetrated the fraud) by honoring them with a large, expensive corporate dinner meeting.

Read the complaint, form your own opinion. But keep in mind, the government has yet to file ITS complaint.

But Wait…There’s More

This has been going on for years, now. So, one wonders, what happened to the WellCare officials who (allegedly) perpetrated these frauds?  According to at least one news report, they have all been replaced since then, and there is an ongoing criminal investigation into former executives accused of committing  frauds.

Nevertheless, there also appears to be an ongoing feud between the press — specifically Health News Florida — and the Florida state Insurance Commissioner Kevin McCarty, about the whole case. Health News Florida reported on July 1, 2010, that McCarty sent them a letter saying there is “no question” that some of WellCare’s dealings (under former management) were illegal, but that the whistleblower complaint also included “unfounded allegations.”

“Unfounded” or not, someone else in the Florida state government is still very concerned about all that fraud and wants somebody prosecuted: after the whitstleblower complaint was unsealed, the Florida secretary of healthcare administration sent a letter to Florida’s Attorney General and urged him to “investigate and attempt to prosecute officials at WellCare.”

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RAC Reviews for Multiple Issues

July 9th, 2010

Can a RAC review a claim for multiple issues at the same time?

We’ve seen this question from several providers, recently. The short answer is “Yes,” but under certain circumstances, it’s “No”; and so maybe the answer should be “Maybe”?

Timing is everything, in…

Timing, Timing, Timing

In the retail industry (and others), the three most important factors are said to be, “Location, Location, Location.” If that’s true for those industries, then perhaps something similar can be said for our industry, under the new healthcare reform environment.

I submit that at least in dealing with the RACs, the factors might be, “Timing, Timing, Timing.”

Timing is everything, in many things, don’t you agree?

So let me explain what I mean…

How RACs Perform Reviews

RACs have to get issues they want to review approved by CMS before they can do “widespread review” — the term “widespread” evidently refers to multiple records, multiple providers, and/or multiple states. (They can review ANY record on a very limited basis while assembling evidence needed to garner CMS approval for any issue, but that’s another subject…)

Approved Issues Lists

The RACs also have to post a list of approved issues on a public web page, before they can begin conducting records requests, conduct reviews and publish their results — most often in the form of Demand Letters, recouping the payments from the providers.

Once an issue is approved by CMS and posted on the RAC’s website, the RAC uses proprietary software and their own experience to do data mining and analysis of Medicare Part A and Part B claims, which CMS makes available to them. When the RAC identifies claims that they believe show a potential for an improper payment, they can perform one of two types of review: an Automated review, where an error is a certainty just from data analysis; or a Complex review, where an error is considered likely, but cannot be determined without a human review of the medical record for the claim in question.

For an Automated review, the error is certain, by definition, so a Demand Letter is produced and sent to the provider. For a Complex review, an Additional Documentation Request letter (ADR) is send to the provider, and requires the provider to send specific claims records to the RAC for review. The ADR must name the issue being reviewed by the RAC. It must list one issue, and this issue must already be approved by CMS and posted on that RAC’s approved issues web page.

Now, back to the question at hand:  once a RAC recieves a record in house, can they review it for other approved issues at the same time?

The CMS Answer

Here’s how the CMS RAC FAQs answer that exact question: READ CAREFULLY…

Question: Can the Recovery Audit Contractor (RAC ) do a medical necessity review on a claim that they originally reviewed for DRG validation?

Answer: At this time, if the RAC has already requested documentation and issued a review results letter to the provider for a DRG Validation, the RAC will not be allowed to re-review the claim again for medical necessity. However, if both issues are approved (DRG Validation and medical necessity) prior to the request of the additional documentation, the RAC may conduct both reviews simultaneously.

(see Answer ID 10007, posted 4/23/2010)

Let’s analyze this a bit…

So that’s…At Least Two Answers?

First, notice the phrase, “At this time,…” So, CMS might change their policy at a later date. Form your own opinion about the likelihood of that.

Second, while the first sentence mentions the review results letter, which appears to place a stop on multiple issue reviews on a claim (that was the NO answer), the second sentence allows multiple issue reviews on the same claim, as long as both issues were approved for review before the ADR was sent out for that claim (that’s the YES answer).

So, as long as both issues were approved for review before an ADR was sent out, it appears that a single claim can be reviewed for multiple approved issues.

However, if a new issue is approved after a Review Results letter was sent out for a previously approved issue, the RAC is not allowed to re-review that same record for the new issue.

And Maybe a Third Answer?

What the statement does NOT address is this: can the RAC send out a new ADR for the same claims, under the newly approved issue? (That’s what I call the MAYBE answer.)

Well, we would expect that the RAC could submit an ADR for any approved issue, even if the record has already been reviewed for something else… but we’re going to send this question in to CMS and see what their answer is, which we will then post here…

So, stay tuned.

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