New RAC Web Site Tells Hospitals What to Expect for Audits

HealthLeaders Media Staff, August 13, 2009

HealthDataInsights, Inc. (HDI), launched its new RAC Web site, and posted the first set of issues eligible for RAC review throughout all 20 RAC Region D states and territories yesterday.

The list of issues will likely be familiar to healthcare providers who saw those announced by Connolly Healthcare last week. HDI has posted the following approved issues:

  • Neulasta (HCPCS code J2505). RACs will review claims submitted with the total number of milligrams instead of one unit per 6mg. Providers should submit claims for J2505 so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs.

  • Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit. Certain service codes are specific to patients of a specific age and should not be applied or billed for patients who exceed the age limit defined by the CPT code.

  • Once in a Lifetime. Certain procedures are only performed once in a person's lifetime. RACs will seek to identify claims paid for those procedures for more than one service date.

  • Excessive Units—Untimed Codes. When reporting service units for untimed codes (excluding modifiers -KX and -59) where the procedure is not defined by a specific time frame, the provider should enter a "1" in the units bill column per date of service.

  • Excessive Units—Blood Transfusions. Providers should bill blood transfusions with a maximum of one unit per patient per date of service.

  • Excessive Units—Bronchoscopy. Providers should bill bronchoscopy services with a maximum number of one unit per patient per date of service.

  • Excessive Units—IV Hydration. Providers should bill IV hydration with a maximum number of one unit per patient per date of service.

"These issues are perfect for automated reviews," says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. "These issues are definitely clear cut. RACs wouldn't need to request medical records for these."

But that doesn't mean the issues the RACs have chosen to begin with aren't surprising. Mackaman says many providers expected RACs might audit for incorrect Neulasta billing and speech therapy untimed codes. But other choices, such as the newborn codes billed for patients who have exceeded code age limits and "once in a lifetime" procedures, are unanticipated.

"It's not exactly what we may have expected," Mackaman says. "But it must be that they found these to be important through their data mining."

HDI's list of approved issues also includes the date CMS approved the issue, as well as relevant claim types for each issue, and where providers can find additional information on each topic.

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