Tracking RAC Communications and Appeals GET READY - SET - GO!

Tracking RAC Communications and AppealsGET READY - SET - GO! Presented by: HomeTown Health September 23, 2009

GET READY:Integrating a new process into your current workflow is challenging and requires 5 important steps:

Step 1: Management Support • Have the physicians, board and management agreed that the change is needed and they will support it? • QUESTION: What have you done to prepare your Board, Physicians and Management for the changes required by Medicare to address RACS?

Is the new process properly funded and staffed with the right people? • QUESTION: Have you estimated your cost to manage RAC/MAC Audits and Appeals?

Step 2: Funding and Staffing Staffing – 1 additional FTE to manage record request, appeals, claim tracking = $30,000 Educational compliance program to prevent future takebacks = $6,000 Cost of new document mgmt, scanning equipment = $22,000 FED EX Cost calculated at 100 records per month at $15 ea = $1500 Appeals Mgmt Program & Consulting – 50 claims per mo X 12 = 600 claims X avg cost to appeal to 3rd level @ $1000 ea. = $600,000

KEEP IN MIND: • Average takeback = $4000 X 600 claims annually = $2,400,000 • Cost to manage 600 claims appeals @ $1,000 ea = $600,000 80 % Turnover rate = $1,920,000 Overturned 20% Denials = $480,000 Recouped NET RETAINED: $1,320,000 VS. $2,400,000 loss

Step 3: Set Expectations • Have you set the right expectations at the front in order to hold people accountable? • QUESTION: Are you sure that your managers and staff understand the seriousness of the RAC Audits and their responsibility to respond in a timely manner.

Step 4: Communicate • How have you communicated the changes and gained buy-in from those performing the work? • QUESTION: Have you included front line staff members in the detailed action plan?

Step 5: Measurement • How are you going to measure the success of the new process? • QUESTION: What is your measure of success? • 100% of RAC letters logged, scanned and forwarded for appeals determination • You can’t manage what you don’t measure.

Remember, it is about the people. If the people are not fully engaged then the program will sputter and stall. • Most individuals do not like change; however, if you make them part of the process of change they will feel empowered and more in control of their future. • Naturally there will still be those that resist the inevitable outcomes. • Just remember, it is important that everyone has a voice. Reference: http://www.compaid.com/caiinternet/ezine/Herron-change.pdf

SET:Now that you have done your homework - You must have an implementation and execution plan:

1) Development of new Policy and Procedure • The key to successful change is to hold people accountable by putting it in writing. • Policies are in essence statements of how the organization will conduct a certain process. • Management is ultimately accountable for whether staff follow the approved policies. • Having the “right” policies can ensure that an organization is in compliance with legal requirements and ‘best practices’ — however — educating board members, supervisory and line staff about the new policies, as well as ensuring the fair and consistent enforcement of the policies is critical.

EXAMPLE OF POLICY AND PROCEDURE • POLICY AND PROCEDURE • ____ HOSPITAL has adopted the following policy and procedure on the submission of Medical Records to comply with the requirements of Connolly Healthcare, the Medicare Recovery Audit Contractor (RAC) or Medicare Administrative Contractor (MAC). • The HIM Department will follow the Medical Record Submission Requirements stated below: • The Provider Medical Record (MR) must be submitted on Paper, CD, or DVD no later than 30 days from the date of the medical record request letter. • SEE SAMPLE POLICY

2) Installation of New Equipment, Software, Supplies • Make sure that you have ordered any new equipment or supplies that will be required to implement your new process. • i.e. – Document management, scanners, CD’s , FED EX supplies, etc. • It is helpful to set up a timeline to make sure you have planned accordingly and that you are prepared at time of implementation.

Set up tracking systems NOTE: Key Timeframes As you review the overpayment, below is some important information and key timeframes (15, 30, 40 and 120 days) to consider

PAGE 2

What are the timeframes to stop recoupment: First Opportunity: To avoid the recoupment, the appeal request must be filed within 30 days of the demand letter. CAHABA request that you clearly indicate on your appeal request that this is an overpayment appeal and you are requesting a redetermination. Send your appeal request to: Contractor Name Address City, State and Postal ZIP Code

What are the timeframes to stop recoupment: Second Opportunity: If the redetermination decision is 1) unfavorable Medicare can begin to recoup no earlier than the 61st day from the date of the Medicare redetermination notice (Medicare Appeal Decision Letter), or, 2) if the decision is partially favorable, we can begin to recoup no earlier than the 61st day from the date of the Medicare revised overpayment Notice/Revised Demand Letter or, 3) If the appeal request was received and validated after the 60th day Medicare will stop recoupment. The address and details on how to file a request for reconsideration will be included in the redetermination decision letter.

What are the timeframes to stop recoupment: What Happens following a reconsideration by a Qualified Independent Contractor. Following decision or dismissal by the QIC, if the debt has not been paid in full, Medicare will begin or resume recoupment whether or not you appeal to any further level. NOTE: Even when recoupment is stopped, interest continues to accrue.

3) Educate your Staff • Policy and Procedure • Training on new tools i.e. spreadsheet, tracking software or new equipment • Medicare coding & billing guidelines

4) Now that you have developed your new policy and edcuated your staff - Have a practice run • Identify a time and a date that the new processes will begin and, at least one week before that date, allow your staff to begin using the new equipment and processes to ensure that everything runs smoothly when the implementation is over and the start date arrives.

GO !On implementation day - use this checklist to ensure that everyone understands and is completing their new procedures correctly.

1) What is the measurement of success on Day 1 • EX: 80% of all records requested are scanned and saved to the new server

IMPLEMENTATION DAY CHECKLIST: • Staff have good understanding of the project and performing new tasks at above average or average • Copies of new procedures distributed to staff • New equipment worked properly • Staff have completed training on new doc mgmt equipment • RAC Activity Tracking & Reporting systems in place

CMS/Connolly RAC Updates • Discussion on Approved Issues = Top 5 Medicare target areas • Unit Coding • grams vs. milligram, • number or procedures per day (e.g., appendectomy, colonoscopy) (automated review) • blood transfusion 36430, billed 1 service per pint rather than 1 service per transfusion session (automated review) • Untimed codes / speech/hearing therapy 92507, billed 1 service per 15 minutes rather than 1 service per session. Processing manual 100-5, Chap 5, Sec 20.2 (automated review) • Neulasta/Pegfilgrastim J2505, billed 1 service per mg when the definition of the code is 1 service per 6 mg vial. Transmittal 949. (automated review)

IMPORTANT TIE IN TO MUE’s • QUESTION: What is a Medically Unlikely Edit (MUE)? • Answer:An MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. The MUE program provides a method to report medically reasonable and necessary UOS in excess of an MUE.

MUE’s • Question #8733:What is the CMS Medically Unlikely Edit (MUE) program? • Answer:The CMS Medically Unlikely Edit (MUE) program was developed to reduce the paid claims error rate for Medicare claims. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment.

MUE’s • Question #8736:How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value? • Answer: Since each line of a claim is adjudicated separately against the MUE value for the code on that line, the appropriate use of Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. • CPT modifiers such as • -76 (repeat procedure by same physician), • -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), • -91 (repeat clinical diagnostic laboratory test), and • -59 (distinct procedural service) will accomplish this purpose. • Modifier -59 should be utilized only if no other modifier describes the service.

MUE’s • Question #8735:How are claims adjudicated with Medically Unlikely Edits (MUEs)? • Answers:All CMS claims processing contractors adjudicate MUEs against each line of a claim rather than the entire claim. Thus, if a (HCPCS)/ (CPT) code is reported on more than one line of a claim by using CPT modifiers, each line with that code is separately adjudicated against the MUE. • Fiscal intermediaries (FIs) and Part A/Part B Medicare Administrative Contractors (A/B MACs) processing claims with the Fiscal Intermediary Shared System (FISS), return to provider claims with units of service exceeding the MUE value for the HCPCS/CPT code on the claim line. The claim line is not denied. Therefore, no appeal process exists for MUEs for claims processed by FISS. • Carriers and A/B MACs processing claims with the Medicare Claims System (MCS) deny the entire claim line if the units of service on the claim line exceed the MUE value for the HCPCS/CPT code on the claim line. • Since claim lines are denied, the denial may be appealed. DME MACs processing claims with the VMS system deny the entire claim line if the units of service on the claim line exceed the MUE value for the HCPCS/CPT code on the claim line. Since claim lines are denied, the denial may be appealed.

Blood Transfusions • CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one (1) per session, regardless of the number of units transfused on that date of service. • According to Carla Engle, MBA and product manger for MediRegs, "CMS on March 4, 2005, issued long-awaited Medicare blood billing guidelines for hospital outpatient departments. • As stated in the original 2001 guidance, these 2005 guidelines also address that hospital outpatient departments may bill Medicare for the transfusion procedure only once per day, regardless of the number of units or different types of blood products transfused." • CMS Pub 100-04, Ch. 4, § 231.8

Blood Transfusion - MUE • CPT codes 36430, 36440, 36450, and 36455 MUE TABLE CAHABA / MAC will prevent future takebacks/claims paid in error through these MU edits.

Untimed Codes • For CPT Codes (excluding modifiers KX, and 59), for which a procedure is not defined by a specific time frame (untimed codes), the provider should enter a one (1) in the units-billed column per date of service. • According to Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, "this is a rehab issue, although not stated as such. The CMS references listed on the Connolly Web site are from the Medicare Claims Processing Manual chapter on hospital outpatient rehab, including CORFs and rehab agencies, with another reference to Transmittal 19 which gave direction to billing rehab service codes.“ • http://www.cms.hhs.gov/transmittals/downloads/R1019CP.pdf

IV Hydration Therapy • Based on the definition of CPT 90760 (excluding claims modifier-59), the maximum number of units should be one (1) per patient, per date of service. Beginning 1.1.09, code 90760 was replaced with code 96360. • According to Ashley L. Brandon, MBA, RHIA, CCS, internal coding audit coordinator for Precyse Solutions, "IV hydration therapy documentation must be clearly noted with actual start and stop times for each bag, the route of administration, and sufficient documentation to decipher whether a flush versus hydration (exists)." Examples of documentation that cannot be charged are notations of "Over 1 hour" as ordered; INT removed/hep-lock discharged; 800cc infused with no start or stop times; marked through and/or illegible administration times; times that do not make any sense (i.e. start time 10:09 with stop time 9:19); and medically unlikely amount of med versus route example "NS 200cc per hour flush." And finally, says Brandon, "if it's not documented, it's not done."

Other approved Issues • Bronchoscopy Services CPT Codes 31625, 31628 and 31629 should be billed with a maximum number of units of one (1) per patient, per date of service (excluding claims with modifier 59) and reported with one unit per date of service. • Once-in-a-Lifetime Procedures By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime. • Pediatric Codes Exceeding Age Parameters Newborn/Pediatric CPT codes being applied/billed for patients who exceed the age limit defined by the CPT code. • J2505: Injection, Pegfilgrastim/Neulasta, 6 mg By definition, HCPC Code J2505 represents 6 mg per unit. The code should be billed at one (1) unit per patient, per date of service.

Other RAC Findings: • Carrier (MAC) IssuesRemittance Advice (RA) to Provider: • N432“Adjustment based on a Recovery Audit” • RAC IssuesDEMAND Letter to Provider • Appeals Timeline starts on the date of the Demand Letter plus 5 calendar days. • Day 41Carrier (MAC) Recoups by Offset • Unless Provider has paid in full or filed appeal by Day 30 • If an overpayment is identified by the RAC, the provider must also refund the patient or the secondary payer any amounts collected from them. • There is no claims limit for Automated Reviews because no medical records are requested.

THE TOPPER: • The RAC is permitted to ask for medical records for the same issue every 45 days; • So if you believe you have an extensive incorrect claims issue, do a self-audit and work out a deal with the Carrier for repayment so the RAC is not involved. • (It will cut the RAC out of their percentage.)

IN Summary: RACS TRACKING IS EVERYONES JOB!! • EVERYONE–If mail lands on your desk from the RAC, give it to _____________ ASAP (keep it in the envelope for the postmark) • Coding–Your expertise will be needed for internal reviews as well as looking at the results from RAC audits • Medicare biller–Watch for denial/edit patterns that could raise flags so we can address the issues before RAC does • Reimbursement–Watch for the remark code N432 “Adjustment based on a recovery audit” on remittance advices and report to ____________ ASAP • Refund–Overpayments identified by RAC also means secondary payorsand/or patients may need to be refunded • Compliance–Serve as contact and coordinator to make sure we act and respond within the required timeframes

Tracking RAC Communications and Appeals GET READY - SET - GO!