Revenue Cycle

Self-examination can help ensure compliance with new CMS-approved audit issues

Recovery Auditor Report, August 20, 2009

By William L. Malm, ND, RN
Connolly and HealthDataInsights (HDI) have released their first set of “approved issues” and facilities now know what they are likely to be confronted with in RAC reviews. But even with the identified issues, facilities still struggle with how to prepare and examine themselves effectively. Fortunately—or perhaps unfortunately—the first set of approved issues will be of an “automated” review nature, most of which involve a unit of service that is greater than one (>1) on the claim.
The following approved issues are unit-based edits for which any facility can review internally:
  • Neulasta: The RAC auditors found that the units of service were inaccurate secondary to a description change. “Neulasta (HCPCS code J2505) Claims submitted with the total number of milligrams instead 1 unit per 6mg. Claims for J2505 should be submitted so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs.”  Facilities can easily audit this issue internally. For example, the chargemaster should be reviewed to ensure that the billing description and units are correctly submitted as “Neulasta per 6mg” with a unit of one. Then the chargemaster staff should review the “multiplier” that converts the dispensing dosage to the billing dosage. Secondarily, utilize your chargemaster (CDM) to identify the volume of units, and then pull actual claims with that chargemaster unique identifier and audit them against the ordered and dispensed units documented in the medical record. The key here is to audit yourself and correct any ongoing patterns of erroneous behavior.
  • Blood transfusions: “Blood Transfusions should be billed with a maximum of (1) unit per patient per date of service.”  Once again, this issue is easily identified internally. In this case, a “hard stop edit” should be placed in the billing system to ensure that no claim is submitted with a unit of service in excess of one (>1) on any Medicare claim. Additionally, a retrospective sampling review of claims from 10/01/07 would be beneficial in to identify whether claims were being submitted with units in excess of one. The same methodology should be employed for Bronchoscopy, which also has a maximum of one unit per day.

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