Service-Specific Example of an Overpayment Identified by Recovery Audit Contractors

Home

Articles

Written by Stephanie Wasek

Wednesday, 16 July 2008

This is a review of claim facts and corrective actions taken for excisional debridements (complex review, incorrect coding), one of the top five overpaid services in inpatient hospitals, as explained in CMS's recovery audit contractor evaluation report.

Claim facts:

The hospital coder assigned a procedure code of 86.22.

In the medical record, the physician writes ?debridement was performed.?

Coding Clinic 1991Q3 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 82.26."

The RAC determined that the claim was INCORRECTLY CODED and issued a repayment request letter for the difference between the payment amount for the incorrectly correctly coded procedure and the payment amount for the correctly coded procedure.

Corrective actions:

Hospitals can be more careful when submitting claims for excisional debridement.

Medicare claims processing contractors can remind hospitals about the importance of following the coding clinic guidelines when submitting claims for excisional debridement.

Read more about the RAC program and the evaluation report. Read a list of the services that received the most in overpayments.