Archive for May, 2011|Monthly archive page

CMS Sets National 5010 Testing Day For June 15, 2011

In Uncategorized on May 12, 2011 at 6:56 pm

Beginning on January 1, 2012, a federal mandate requires health plans, clearinghouses, and providers to use new standards in electronically conducting certain health care administrative transactions at the heart of daily operations, including claims, remittance, eligibility, and claims status requests and responses.
Upgrading from the current HIPAA 4010A1 transaction standards to the new 5010 standards addresses several key goals:

  • Increase transaction uniformity
  • Support pay for performance
  • Streamline reimbursement transactions

As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions.

Two key factors prompted the upgrade to 5010: 1) the government and industry’s shared goal of providing higher quality, lower cost health care, and 2) the need for a comprehensive electronic data exchange environment for the vastly expanded ICD-10-CM and PCS code set transition mandated for compliance by October 1, 2013.

To this end, the Centers for Medicare and Medicaid Services is encouraging all Medicare trading partners to participate in National 5010 Testing Day on June 15 as part of preparations to comply with the HIPAA 5010 transaction sets by January 2012.

Local Medicare Administrative Contractors will be disseminating information on transactions being tested on June 15 and some Medicaid programs also will participate, with details to come.

RAC Approved Issue #1 — Coding Services Supplemental To Principal Procedure Code (Add-On Codes)

In Uncategorized on May 10, 2011 at 9:15 pm

As discussed in the last post, this blog is going to dedicate some time to highlighting all of the approved issues for Region C’s Recovery Audit Contractor — Connolly.  Without further ado, the first item on Connolly’s list of “approved issues,” as identified by Connoly and CMS, which applies to physicians (as opposed to inpatient or outpatient facilities, ASCs, or DME suppliers) is:  the use of an add-on code without the primary code.  This audit issue is applicable to all of the states within Connolly’s Region C purview, and is applies to dates of service 10/1/2007  forward (however, it is important to note that the date of claim subject to a RAC audit cannot exceed three years from the current date — so, all the date of service must be no further back than May 8, 2008 for an audit sent today).

Pursuant to the CMS Manual, and the AMA’s CPT-Professional Edition, an add-on code designates a procedures which is commonly carried out in addition to the promary procedure performed (as distinguished from incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy), which are not separately billed).  These additional/supplemental codes enable physicians and others to separately identify a service that is performed in certain situations as an additional service, such as additional digit(s), lesion(s), neurorrhaphy(s), vertebreal segment(s), tendon(s), joint(s), or additional time.  These add-on codes are generally readily identified by terminology such as “each additional” or “list separately in addition to code for primary procedure,” or by a “+” symbol.  

Use of an add-on code is only appropriate when the same physician who provided the primary service also provided the additional add-on service.  Additionally, it is imperative that an add-on code never be reported as a stand-alone code — i.e., the add-on code must never be the only CPT code reported, rather, it must accompany the promary procedure code that it represents and enhances.  Finally, the add-on codes must never have the following modifiers appended to them:  -25, -51, or -59.  While all of these elements of the add-on codes are critical to compliant coding, it is the use od the add-on code as a stand alone code – without the primary CPT code – that will trigger a RAC investigation, for billing and subsequent payment of an add-on code without its respective primary code(s), results in unwarranted overpayments, repayment of which will be demanded by the RAC.


RAC Audits… Coming To A Practice Near You!

In Uncategorized on May 3, 2011 at 8:48 pm

When the Recovery Audit Contractors began their investigations into the possible overpayments (and underpayments – to a much, much lesser extent!) made by Medicare, they started with the deep pockets…  with the providers submitting the most claims…  with the hospitals.  In fact, it was widely expressed that it would take some time for the RACs to navigate their way through the morass of facility claims up for review before getting to the physician practices — especially solo practitioners.  Well, my friends, that time has come. 

While the RAC program has been in effect in some form, albeit initially provisional, since 2006, it went national in 2010.  And now physician providers are starting to see audit inquiries of their own.  This is no longer a facility investigation, nor an investigation into the coding and claim submissions of large practices.  It is a systemic audit of all claims — whether from a facility or a medical office, even down to the solo-practitioner.

Key to understanding the RAC process is the knowledge that the RACs are not only manually reviewing claims submissions, but are also utilizing computer algorithms which detect billing/coding abnormalities, prompting further investigation.  The computer will not discriminate based on the size of the provider, and will “review” claims of the 500-bed hospital in addition to the solo-practitioner serving a rural community.  Thus, the RAC impacts everyone, and it behooves everyone to understand and comply thoroughly with RAC audits!

Over the course of the next few months, M.E.D.I.C., Inc. will use this blog as a platform and take the opportunity to educate providers on the RACs – focusing specifically on the issues affecting our clients:  physicians (as opposed to facilities) and DME providers in Region C (the largest of the four RAC regions, covering 39% of the United States:  AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands), for which Connolly serves as the RAC.