1. Here are some areas an ASC should confirm are in place and compliant prior to a RAC audit:
- Coding audits — Ensure your coding auditors review the following:
- Compliance to Medicare CCI bundling rules
- Compliance to Medicare MEU edits
- Compliance to NTIOL lens requirements
- Compliance to Regional MAC LCD requirements
- Documentation
- Ensure your medical records are complete
- Ensure the coder has access to all medical records while coding
- Education of staff — What and when to bill for services on Medicare beneficiaries
- Ensure all business office staff is given the current Medicare billing rules (Part B Manual for ASCs)
- Provide CCI edits to coder – including the proper use of the -59 modifier
- Ensure all errors from a coding audit are reviewed with coder, and those changes are understood by everyone involved to avoid future mistakes
- Ensure all staff understands that they can only bill for documented services and items
- No assumptions
- No “always” when determining if an item is used
- No “always” when determining if a physician performs a procedure if he doesn’t mention it in the documentation
- Always use physician confirmed documentation
2. Here are some of the resources available with the information ASCs need to know and understand Medicare rules. The ASC is responsible for obtaining this information on its own. Telling a RAC auditor you did not know the rules is not going to absolve your ASC of an overpayment.
- The Part B manual for ASCs
- Provides the billing rules for an ASC
- Provides what items and services can be billed in addition to the surgical or procedure CPT
- Provides rules on pass thru items, including mark up and quantity limitations
- CCI edits and MUE lists
- Medicare offers these lists and edits on their website or they may be purchased thru one of the national vendors (or may already be part of your coding software)
- CMS websites — These are free sites with many documents related to RAC areas of review, states to be audited, timelines, deadlines, and forms.
- CMS: cms.hhs.gov
- Federal Business Opportunities: fbo.gov
3. Unfortunately, you cannot foresee the random selection of a facility for a RAC audit. Keep in mind, RAC contractors cannot go back more than 3 years from the date of the initial determination of a claim. A facility that falls out of the normal range in certain areas is more likely to be selected for a RAC audit.
- Higher than the norm gross charges for a specific service or procedure. For example, if the market rate for CPT 66984 (cataract w/IOL) is 9,000.00 and your facility charges 22,000.00, then you may be selected as falling outside the normal charges. Even though ASCs are not paid based on their charges, this is the number being used by RAC contractors.
- Overcharging pass thru items above the Market average (such as the cost of brachytherapy seeds are four times the amount of other ASCs)
- Overbilling separately payable services — Incorrect quantity, coding for radiology that was not integral to the surgical service, lenses that do not qualify as NTIOLs
- Excessive unbundling of services
- Overuse of the -59 modifier
4. What can I do if I want to appeal the RAC findings?
- Beware of the deadlines, if you are late you forfeit your appeal rights
- Be prepared to defend your coding and billing with a copy of the ASC manual from your MAC defining the practice you used.
- Provide copies of invoices to prove an NTIOL was used on every case
- Have documentation from the medical record to support the 59 modifier was valid for each CPT
- Have an MUE list to prove quantity is correct
5. You may also email any questions regarding a claim reviewed by a RAC to RAC@cms.hhs.gov.
6. RAC contractors are not responsible for the education of correct Medicare billing. Regional MACs are required to provide this training.
Learn more about the Texas Ambulatory Surgery Center Society.
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