When you look at the list of topics that the RAC is investigating in Region A, you’ll see that the majority of them relate to inpatient and outpatient services. This makes sense, when you consider that the RACs arcade percentage of the money that they recover. A larger bill means a larger percentage of the returned to the RAC. But there are some areas of concern for physicians in the list.
Infusions, injections, and medications are on the list for both outpatient facilities and physician services. The infusion codes are not new, but they can be confusing. If your practice is doing anything but just an IM injection, be sure to review the rules for infusions. Also, medications have HCPCS codes that define what one unit of the medication is. Set up an alert for an unusual number of units being billed for any medication. There is a long list of medications on the RAC list, and practices that provide infusions should look at this list.
Evaluation and management services appear on the RAC list. These include some automated reviews to be sure that a new patient visit is not being billed and paid when it should be an established patient visit, and that only one E/M service is billed and paid by anyone physician on a calendar date. Using an incorrect place of service continues to be a concern, because services are paid in a variable rate based on place of service. Global services are on the list including pre-and postop visits in the global. Observation admissions and discharge on the same calendar date and observations of less then 8 hours are being reviewed, as are I hope the coach starts today annual wellness visits and allergy services on the same day as an E/M visit.
There are some perennial favorites of course. These include: billing for an add-on code without a primary procedure; reporting services for a patient who is dead; duplicate billings; diagnostic colonoscopy; incorrect use of the bilateral modifier; and therapy claims that are over the maximum allowance for the year. Cardiac monitoring, IMRT, and MOHs surgery make the list along with diagnostic tests including MRA, nerve conduction, EKG, MRI, CT scans and chest x-rays for reasons that are not medically necessary.
When I was speaking with a group of surgeons recently I joked that the way to reduce the risk of billing Medicare to zero was not to bill Medicare. Of course, surgeons know about risk. The correct response is to look at the list and identify services on the list that your practice performs. Then, review the coding rules and reimbursement policies including national and local coverage determinations for those services that you perform frequently. Volume increases risk. If there’s a service on the list you perform once a month you’re at lower risk than if it there’s a service that you perform daily. Start with high-volume services and services with high payment.