RAC Readiness Webinar - What's Going On With the RACS?

1. RAC Readiness Webinar - What's Going On With the RACS? Presented by: HomeTown Health January 27th, 2010

2. Topics for Today’s Meeting: • Connolly RAC Update • Review of New Issues Posted • CMS Provider Login Portal • Update on Letters requesting Medical Records • Review of Medical Record Submission Process • Clarification on Cahaba Review of CBC Lab Orders • Condition Code 44 and the RACs • AHA and HCPro Article Updates

3. Connolly RAC Update

4. New Issues Posted-Dec. 5, 2009 • Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255 • Cirrhosis and Alcoholic Hepatitis with MCC: MS- DRG 432 • Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872 • Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989 • Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987 • Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168 • Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983 • Other Respiratory System O.R. Procedures with CC: MS-DRG 167 • Other Digestive System Diagnoses with CC: MS-DRG 394 • Inflammatory Bowel Disease with CC: MS-DRG 386

5. Major Gastrointestinal Disorders and Peritoneal Infections with CC: MS-DRG 372 • Other Respiratory System O.R. Procedures with MCC: MS-DRG 166 • Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331 • Major Small and Large Bowel Procedures with CC: MS-DRG 330 • Major Small and Large Bowel Procedures with MCC: MS- DRG 329 • Major Chest Procedures without CC/MCC: MS-DRG 165 • Major Chest Procedures with MCC: MS-DRG 163 • Major Chest Procedures with CC: MS-DRG 164 • Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207 • Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871 • Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981 • Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982 • Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988 • Coagulation Disorders: MS-DRG 813

6. New Issue Posted-Dec. 24, 2009 • Medically Unlikely Edit List. A Medically Unlikely Edit (MUE) applies to all HCPCS/CPT codes that are above the maximum units of service that a provider would report for the same beneficiary, on same date of service, and same provider. An error was made in billing these services because more units were billed for a beneficiary than what is medically likely.

7. New Issues Posted-Dec. 29, 2009 • Budesonide – Dose vs. billed units • J7605 Arformoterol, (Brovana • Q4099 Formoterol fumarate (perforomist) • Nebulizer, demonstration and evaluation Units billed • Adenosine – dose vs. units billed • Barium swallow studies units billed

8. New Issues Posted-Dec. 30,2009 • Peritoneal Adhesiolysis with MCC: MS-DRG 335 • Nonextensive Burns: MS-DRG 935 • Other Kidney and Urinary Tract Procedures with CC: MS-DRG 674 • Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928 • O.R. Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876 • Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC: MS-DRG 855 • Infectious and Parasitic Diseases with O.R. Procedure with CC: MS-DRG 854 • Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC: MS-DRG 858 • Infectious and Parasitic Diseases with O.R. Procedure with MCC: MS-DRG 853

9. Postoperative or Posttraumatic Infections with O.R. Procedure with CC: MS-DRG 857 • Postoperative or Posttraumatic Infections with O.R. Procedure with MCC: MS-DRG 856 • Wound Debridements for Injuries with MCC: MS-DRG 901 • Wound Debridements for Injuries with CC: MS-DRG 902 • Wound Debridements for Injuries without CC/MCC: MS-DRG 903 • Other Kidney and Urinary Tract Procedures with MCC: MS-DRG 673

10. New Issues Posted-Jan. 4,2010 • Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256 • Cardiac Pacemaker Revision Except Device Replacement with MCC: MS-DRG 260 • Cardiac Pacemaker Revision Except Device Replacement without CC/MCC: MS-DRG 262 • Other Circulatory System O.R. Procedures: MS-DRG 264 • Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with MCC: MS-DRG 463 • Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with CC: MS-DRG 464 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without CC/MCC: MS-DRG 624 • O.R. Procedure with Diagnoses of Other Contact with Health Services with MCC: MS-DRG 939 • O.R. Procedure with Diagnoses of Other Contact with Health Services with CC: MS-DRG 940

11. Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 575 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576 • Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578 • Other Hepatobiliary or Pancreas O.R. Procedures with MCC: MS-DRG 423 • Other Digestive System O.R. Procedures with CC: MS-DRG 357 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC: MS-DRG 622 • Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC: MS-DRG 623 • Other Digestive System O.R. Procedures with MCC: MS-DRG 356 • Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without CC/MCC: MS-DRG 465 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573 • Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574 • Other Vascular Procedures with MCC: MS-DRG 252

12. CMS Provider Login Portal http://cmsprovider.connollyhealthcare.com/ Several hospitals, including Tanner, have logged in and found their Medical Request Issues logged here. IN ADDITION: Corrie Jarrett has posted a new spreadsheet with all Issues sorted by DRG at www.racshelp.com

13. POLL QUESTIONS • Has your RAC team reviewed the claims affected by the most recent issues posted? • Has your team or compliance officer written corrective action steps as you identify problems and documented improved results?

14. Review of Medical Record Submission Process

15. Medical Record Submission Requirements Provider Medical Record (MR) Submission Requirements (Paper/CD/DVD)DUE DATE: 45 days from the date of the medical record request letter Paper Medical Records Include the original or copy of the medical record request letter from the RAC. If possible, highlight claims on the letter identifying the medical records attached. CD/DVD Medical Record Submission Requirements:AttentionPrior to an ongoing submission of medical records via a CD/DVD, a provider will have to perform a successful test of transferring medical records with Connolly Healthcare. A successful test will be contingent on the below specifications being met:

16. Medical Record Format • Scanned image resolution must be 300 dpi and in black and white • Image format must be in either .TIFF or .PDF format • One image per medical record, i.e., multiple-page image file. For example, a two hundred page medical record will be one file. • The image file name must be the requested claim number. For example if the claim number 123456 is requested, the filename would be 123456.pdf or 123456.tif • Copy of our medical record request letter • The following metadata (excel file or tab delimited text file) must be included with the image submission • Requested Claim Number • Begin Date of Service • End Date of Service • Patient name (first and last name) • Patient DOB • Patient HIC Number • Patent Account/Control Number • Medical record number • Provider Name (full name) • Provider Number • Provider NPI • Number of pages or the file size of the image submitted for acknowledgement purposes • Total number of medical records on the CD/DVD • There should be one entry per image in the metadata file

17. Medical Record Submission • Images are to be sent via CD or DVD in a tamper-proof package • CD or DVD should follow the following naming convention for easy communication, tracking , and reconciling purposes: <Provider ID>_<sent date in MM-DD-YYYY format>_<number of images> • For security purposes it is strongly suggested that all images sent should be encrypted and password protected. • If medical images are encrypted through Winzip, a separate email to the MR address located at www.connollyhealthcare.com should be sent to Connolly with the password needed to unzip the files referencing: <Provider ID>_<sent date in MM-DD-YYYY format>_<number of images> • If medical images are encrypted using PGP, public and private keys to decrypted image files must be established prior to shipment

18. Clarification on Cahaba Review of CBC Lab Orders

19. Q/A: Correct orders for lab services APCs Weekly Monitor, January 8, 2010 Q: All of a sudden we are receiving recoupments for some lab work we performed. The information from our FI/MAC says that there was no order for the CBC with diff. Our internal lab protocol is written to reflect that when a physician orders a CBC, a CBC with diff is performed. It has been through the appropriate internal approvals and the physicians have agreed. What is the deal? A: The FI/MACs are performing CERT (Comprehensive Error Rate Testing) reviews. One of the hot spots right now centers on having complete orders for all services provided. When the physician orders a CBC, this test should be reported with CPT code 85027 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]). Your internal lab protocol also performs an automated differential, which would be reported with CPT code 85025 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count).

20. Although the appropriate people within your facility have approved your internal protocol, this is not applicable to how Medicare or other payers process claims. From that standpoint, the physician has ordered a specific test, but the lab performed and reported a different test. Payers don’t have a copy of your internal protocol or all the reasons that the decision was made to handle this situation in this manner. What they see is that there is no order for the test to be performed because the physician intent was for a “plain” CBC; therefore, the CBC with diff is a non-covered, non-reimbursable service. The test that the physician orders is the test that the lab should perform and report. If the physician intends for a CBC with diff to be performed, that is what the order should read. If your order form is preprinted, then you should include all options on the order form for the physician to indicate the test intended. In this scenario, you would list a CBC, a CBC with diff, and a CBC with manual diff. The physician would then check off the test he or she wants for the patient. If the orders are hand written, the physician has to specify “CBC with diff” in order to show his or her intent.

21. Condition Code 44 and the RACs

22. In a recent HCPro audio conference titled “Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance,” Kimberly Anderwood Hoy, JD, CPC and Sandra McCune, BSN, RN, answered listeners’ questions about proper use of condition code 44. • Q. Can we use condition code 44 if a physician realizes his or her mistake and changes a patient’s status from inpatient to outpatient prior to discharge without review from the utilization committee? • A. The condition code 44 regulations state that the utilization committee and the attending physician must concur when changing patient status from inpatient to outpatient. So if the physician wants to make that change, he or she must notify the utilization review (UR) committee and get their concurrence to use condition code 44. • Q. If a UR case manager is on the UR committee, can he or she fulfill the requirement that the attending physician must agree with a member of the UR committee? • A. No. CMS does not consider case managers or other ancillary members of the committee eligible to make medical necessity decisions. A physician member of the UR committee must make that determination.

23. Guidance on Condition Code 44 • http://medicalcodingpro.wordpress.com/2009/02/18/use-condition-code-44-with-care-to-avoid-becoming-a-rac-target/ • Document posted on www.racshelp.com • INTERQUAL ADMISSIONS CRITERIA: • McKesson is negotiating a special group deal on Electronic Version – • Offer from Richard Gentry

24. AHA and HCPro Article Updates

25. January 11, 2010 - AHA published a RAC update.  The update discussed the fact that Remark Code N432 is still not functioning in the proper manner that it was intended— Remittance Advice Update As we reported in the last RAC Update, CMS’ billing systems have not been able to properly use the N432 code designated for RAC claims and, as a result, the code is not appearing on remittance advices. CMS indicates that the necessary system corrections will be implemented through a two-stage process in April and July 2010. In the mean time, CMS and the RACs are developing an interim solution to allow the RAC remark code to function properly. In addition, CMS is working on a Medicare-wide edit to provide claim-level detail on the remittance advice both when a denial is reported and when the actual recoupment occurs; this should be completed by summer 2010.

26. January 14, 2010 – AHA urges the removal of a Medicaid RAC provision that is currently included in the Senate bill. The bill as it currently stands would extend RAC activity to Medicare Parts C and D and to the Medicaid program, despite the fact that state Medicaid agencies already have the authority to implement RACs for their Medicaid programs. Two-thirds of the Medicaid agencies have rolled out a RAC program.

27. HCPro Article: Your Physicians and RACs Tanja M. Twist, director of patient financial services at Methodist Hospital in Arcadia, CA, offers this tip on the role patient access managers play in a hospital's RAC process: Educate the physicians. The best thing in terms of working with physicians is to go back and show them what happened. “Physicians need to work with office staff to make sure all the necessary data gets over there,” Twist says. "You should be trying to educate physicians on medical necessity.”

28. HCPro Article: MUEs creating cause for concern w/ RACS Connolly Healthcare recently added Medically Unlikely Edits (MUE) for outpatient hospital claims to their CMS-approved list of issues. MUEs are edits that CMS has put into place to limit the number of units for a service for one patient on the same date of service. Previously, if a provider bills over that limit, the claim would be returned to the provider (RTP) and cannot be appealed. A new rule has just been announced that will allow line item denials for MUE’s to be appealed. MUEs are designed to prevent clerical errors and incorrect coding. With added focus on an already uncertain entity, being cautious and aware of these issues is crucial. Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., suggests a number of items providers should consider when attempting to untangle the MUE web:

29. DALE GIBSON HAS WON THE BATTLE ON MUE’s: • Know where to find the appropriate MUE table on the CMS Web site • http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp • Develop an understanding of the current and future CMS guidance to help bypass edits when the units of service are appropriate and discuss with your FI or MAC, if necessary • Create a system to catch these edits prior to submitting the claim and review for possible errors – • DALE –Suggests keeping your own spreadsheet of most common MUE’s • Providers should watch for quarterly changes to the list in the future since CMS has not published all of the edits • HTH will keep you updated on Qrtly changes • NCCI – MUE Guidance from CMS/Trailblazer • http://www.trailblazerhealth.com/Publications/Training%20Manual/NCCI.pdf#14

30. HCPro Article: Setting up for success-handling RAC audits During RAC and MIC audits, healthcare providers face an important task: Making the decision to assemble and internal audit staff or to outsource the work. In light of a struggling economy, this can be a challenging assignment. Outsourcing is not just an option for short-staffed providers. A facility that has yet to undergo the RAC process may not have the familiarity or expertise to accurately handle the audits, resulting in outsourcing by default. For a facility that has both the RAC experience as well as the resources to avoid outsourcing, putting a plan into place can be complicated, but bring you closer to the ultimate goal of becoming RAC proof. Elizabeth Lamkin, associate at Axcel Healthcare Group in Tampa, FL, is the former CEO of Hilton Head Regional Healthcare. Her former facility was part of the RAC demonstration project and developed a successful strategy to manage the audits.

31. According to Lamkin, there are a number of steps to take to ensure compliance: • Assign a physician advisor (PA) to conduct concurrent reviews. The PA can be more flexible in hours, and can help perform chart review along with case managers. • Use existing case management staff, but develop an admissions case manager role to review all admissions within 24 hours. • Use an outside firm for nights and weekends to advise on bed status. The PA will work with the medical staff on compliant documentation for bed status and continued stays.

32. Compliance Steps – Continued Develop an interdisciplinary chart review committee and strong utilization review committee to perform concurrent chart audits and train staff through this process. Use additional staff for the short run to respond to audit requests, if needed, but work with your full-time employees on the ultimate goal of becoming RAC proof by getting it right on the front end. Change your committee structure to support this new world. The goal is 100% compliance and eventually RAC and other post-billing audits will slow down because the standard RAC audit screens will not find errors. Develop your system based on this premise and make it permanent; this will help in the end.