Are you Ready to RAC and/or Roll Over?

1. Are you Ready to RAC and/or Roll Over?

2. Lyman SornbergerExecutive Director Cleveland Clinic Health System Patient Financial Services Cheryl Arnold Senior Director, Business Development and Training Cleveland Clinic Health System Patient Financial Services Rebecca Stewart, CCS, CPC Project Manager, Business DevelopmentCleveland Clinic Health System Patient Financial Services

3. What not to do? Our Florida Experience was Out of Tune Manual Costly Consuming Inconsistent Uncontrolled

4. Purpose of RAC • The RAC program’s mission is to reduce Medicare improper payments through: • The efficient detection and collection of overpayments • The identification of underpayments and • The implementation of actions that will prevent further improper payments

5. Medicare Error Rate in 2007

6. CMS Claims Review Entities

7. What did RAC Recover?

8. CMS Return on Investment Total costs to run RAC demonstration = $205.1M March 25 - July 2008

9. Automated Reviews • RAC makes a claim determination at the system level without human review of the medical record • Coverage / coding determination made through automated review when the following applies: • Certainty the service is not covered or is incorrectly coded, AND • Written Medicare policy • Medicare article • or Medicare sanctioned coding guidelines exist • CPT Statements • CPT Assistant Statements • Coding Clinic Statements • Other determinations made through automated reviews • Duplicate Claims • Pricing mistakes • Units • Discharge Disposition / Transfer DRG

10. Complex Reviews • Reviews requiring human review of the medical record • Where there is a high probability that the service is not covered • Copies of medical records will be needed to support overpayment • Use of proprietary data scrubber identifying cases with highest probability of DRG changes • Medical Necessity 1 Day Stays OBS Incorrect coding 3 day qualifying stay

11. RAC Appeals by Contractor

12. A B D C CMS’ National Rollout PlanSeptember 2008 Region B:CGI Technologies and Solutions, Inc. March 1, 2009 AUGUST 2009 OR LATER October 1, 2008 Although CA was a RAC demo state, California claims will not be available for RAC review from March 2008-Oct. 2008 due to a MAC transition

13. How is the permanent RAC different?

14. Improper Payments excludedfrom Statement of Work Excluded • Services provided under a program other than Medicare FFS • Cost report settlement • Service dates > 3 years • Paid earlier > 10/1/07 • Claims where beneficiary is liable for the overpayment • Random selection of claims • Claims identified with special processing numbers • Prepayment review • Claims already reviewed by another entity • Claims in review for potential fraud by CMS, OIG, others

15. RAC Medical Request Limits 200 MAXIP / OP Combined

16. Inpatient Hospital

17. Other Part B Billers

18. Demonstration Phase Target Areas

19. One-Day Stay • Large numbers of inpatient one-day stays - clinically appropriate for an outpatient setting • Focus is on chest pain and back problems • Inappropriate one-day stays linked to incorrect admission status • Medicare rules – the attending physician should determine a patient’s admission status when the patient is admitted to the hospital

20. Improper DRGs • 416 – Septicemia >17* • 217 – Wound debridement & skin graft* • 468 – Extensive OR procedure unrelated to principal dx • 124 – Circulatory disorders except AMI with cardiac cath & complex dx • 475 – Respiratory system diagnosis with vent support* • 076 – Other respiratory systems OR procedure with CC • 415 – OR procedure for infectious & parasitic disease • 082 – Respiratory neoplasms • 477 – Non-Extensive OR procedures unrelated to the principal dx • 397 – Coagulation disorders* • 148 – Major small & large bowel procedures with CC * Most DRG changes by the RAC

21. Improper DRG Example • Septicemia (DRG 416). • Often hospitals report a principal diagnosis of Septicemia (038.9), but the medical records indicate the diagnosis of urosepsis. • According to Coding Clinic, urosepsis does not have an ICD-9-CM diagnosis code; rather it is coded as urinary tract infection (599.0) as referenced in ICD-9-CM. • Unless the physician states in his documentation that the condition is sepsis or septicemia, urosepsis would be coded as a UTI.

22. Septicemia vs. UTI UTI 599.0 Septicemia038.9 MS-DRG 690 Kidney & Urinary Tract Infections w/o MCC 8000 ALOS 4.3 days MS-DRG 872 w/o mech vent & w/o MCC 1.3783 ALOS 7.7 days Est. $6,744 Est. $3,914

23. Another Improper DRG Example • Respiratory system diagnosis with vent support (DRG 475) • Principal diagnosis on claim did not match the principal diagnosis in the medical record. • Principal diagnosis definition - “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital”. • DRG 475 (Respiratory system diagnoses) and DRG 468 (extensive OR procedures unrelated to the principal diagnosis) are the most common DRGs with this problem. • Due to incorrect coding.

24. Debridement • Procedure code of 86.22 (Excisional debridement of wound, infection or burn). • Documentation issues: The physician writes “debridement was performed via minor scissoring.” • Coding Clinic 1991 Q3 states “Unless the attending physician documents in the medical record that an excisional debridement was performed (definite cutting away of tissue, not the minor scissors removal of loose fragments), debridement of the skin should be coded to 86.26, non excisional debridement of skin… Any debridement of the skin that does not meet the criteria noted above or is described in the medical record as debridement and no other information is available should be coded as 86.26.” (ligation of dermal appendage).

25. Inpatient Procedures Unrelated procedures: • Procedures performed which are unrelated to the reason for admission. • Physician must document diagnoses related to the procedure “why was the procedure done?” Inpatient only list: • Inpatient only procedures performed in an outpatient setting. • CMS created the ‘inpatient only list’ based on several factors including the nature of the procedure and the need for at least 24 hours of post op recovery time before the patient is discharged home. 25

26. Incorrect Discharge Status • A patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter. • The discharge status code occasionally affects DRG and reimbursement. • Hospitals are not adequately updating Medicare on the discharge status of patients. As a result, Medicare often pays two separate locations for the treatment of a single patient. • CMS developed a list of transfer DRGs under the Post-Acute Care Transfer (PACT) policy. PACT requires hospitals to report accurate discharge disposition codes even when a patient's disposition changes after discharge. • RAC will catch claims that overlap with another post-acute care claim.

27. Example of Incorrect Discharge Status Overpaid $

28. Three-day length of stay transferred to a SNF • Inpatient patients that appear to be held in the hospital for three days when the care could have been provided in an outpatient setting. • When a patient is admitted as an inpatient for a minimum of three days, the patient’s 100 days of covered SNF benefits are reactivated. • RACs will focus on the SNF patients with diagnoses indicating back problems that could be treated as outpatients, rather than inpatients. 1 2 3

29. Inpatient Rehab • Inpatient rehabilitation must meet medical necessity criteria (HCFA Ruling 85-2 and Medicare Benefit Policy Manual Section 110). • Inpatient rehabilitation patients must have a condition that requires medical rehabilitation at a hospital level. Including the following: • Intensive rehabilitation (at least three hours per day) • Require care by physician • Require 24-hour care by registered nurse • Require a coordinated care program • Expected to achieve significant improvement in a reasonable period of time • Reasonable length of stay • Realistic rehabilitation goals • RAC will determine if inpatient rehab stays meets above criteria.

30. Neulasta – Wrong # Units (OP) • Neulasta (generic Pegfilgrastim) - used to treat neutropenia (lack of certain white blood cells) caused by receiving cancer chemotherapy. • HCPCS code J2505 (Injection, pegfilgrastim, 6 mg). • CMS noted that many providers billing multiple units of J2505 were consistently billing 6 units per date of service (which equals 36 MG of Neulasta given). • HCPCS code J2505 is usually administered via a pre-filled syringe of 0.6 ML, which is equivalent to 6 MG of Pegfilgrastim. • Providers should ensure they are billing for the number of multiples of 6 MG administered rather than the number of MG administered.

31. Incorrect Units Outpatient Hospital Speech Therapy • CPT codes 92506-92526 . • Speech therapists often evaluate the patient for varying amounts of time, depending on the condition of the patient. • The CPT definition of the speech therapy codes do not include time increments. • Speech therapy services are often reported more than once per encounter (per 15 minute increments). • RAC found the error based on CPT code and units. The patient’s medical record is not reviewed. (Automated Review, Medically Unnecessary Services).

32. # of Units – Medical Necessity Blood transfusions • CPT 36430 (Transfusion, blood or blood components). • Often billed as 1 unit per pint rather than 1 unit per transfusion session. • Blood transfusion – 36430 should be charged only ONCE per day, regardless of the number of units given.

33. Evaluation and Management • Use with a Modifier -25, same day as a procedure. • Utilized within the surgical global period. • New versus established. • Levels of Service may or may not be included (currently under review by AMA and the physician community). Will notify physician community prior to allowing RACs to review.

34. Get Ready for RAC Today Develop RAC Steering Committee Assess Current Risk Develop Processes for Managing the RAC Roll-Out Develop RAC Tracking Tool

35. Development of RAC Steering Committee HIM, Compliance, Internal Audit, Finance. Case Management, Coding, CDM, Nursing / Medical Staff Work Teams • Toolkit Team – Baseline statistics to assess risk, determine future tracking and reporting tools including dashboards • Logistics Work Team – development of operating model • Education / Training and Communication • Process Improvement Work Team • External Relations Work Team – Lessons learned, collaborative opportunities, etc.

36. RAC Risk Assessment based on Benchmarks Source differed based on what we were looking at: Pepper, Volume based on Medicare visits Pepper Report State Median Prin. Dx 518.81 IP

37. Audits Tools

38. RAC Audits based on those areas identified as Potential Risks 100% 98% 98%

39. Process Improvement Initiatives Develop a plan and identify actions needed Define responsibility Determine desired outcome

40. Education is Key Case Management Committee Meetings Newsletters Education Coders Physicians Education Forums Individual Biller

41. Developing the Operating Model • How and where will requests be tracked? • Who will be responsible for tracking the requests? • How will the medical records be assembled and who will be responsible? • How will utilization review examine the cases and how will risk be assessed? • How will withhold dollars be tracked? • Who will analyze the RAC denials and manage the appeals process?

42. Team RAC – Front End Processes

43. Team RAC – Risk Assessments

44. Team RAC – Appeals / FTE Allocation

45. Timeline – Receipt of Initial Request

46. Timeline - Receipt of Demand Letter to Appeal

47. Levels of Appeal Must be filed within 60 days Level 5 Court Appeals Board has 90 days for determination Must be filed within 60 days Level 4MAC Review Must be filed within 60 days ALJ has 90 days for determination Level 3Administrative Law Judge Must be filed within 180 days QIC has 60 days for determination Level 2 Reconsideration Must be filed within 120 days Level 1 Re-determination appeal to FI/MAC MAC / FI has 60 days for redetermination Note: Interest begins accruing during the appeal process. If appeal is denied, hospital is required to pay interest.

48. Develop Tool to Track RAC Process • Initial Chart Request • RAC Due Dates (Chart requests / Appeals, etc.) • Patient Demographic Information including MRN & Acct # • Discharge Date • DRG or APC • Total Charges, Receipts and Take backs • Automated / Complex, RAC Findings • Alerts on Impending Deadlines • Ability to Build Risk Timeframes • Ability to Easily Monitor Backlog

49. What does the tool need to do? • Monitor outcomes • Predict trends based on current claims volume • Calculate financial impact • Indicate percentage appealed and overturned • Reveal root causes of take backs; i.e., documentation, coding, etc. • Help prevent future cases through education and training

50. Review Vendor Functionality Make sure you are on the same page regarding RAC deadlines! Make sure your tool tracks responsibility Make sure you tag “risk” levels to each claim – will help to speak to next steps and provide Finance reporting / reserves.