Revenue Cycle

Q&A: RACs and readmissions

Recovery Auditor Report, March 19, 2009

Q: A provider does three different procedures in three different days. Is this acceptable? Are RACs looking at this?
A: It may be acceptable to unbundle procedures into multiple steps in some cases. But if it appears that the only reason to do so would be to maximize billing or if there is a standard of care issue, it will mean a denial and possible investigation. This falls into the category of readmissions, which CMS is looking at very carefully. I would expect that admissions within 30 days of each other will be under scrutiny not only by RACs but by MAC's and QIO's as well. If a procedure is unbundled into multiple visits, the physician must clearly document the reason and the hospital must be prepared to explain why this would not fall into a "leave of absence" category.

Editor’s note: Joseph Zebrowitz, MD, executive vice president and senior medical director of Executive Health Resources in Newtown Square, PA, answered the previous question.

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