RAC thoughts

As you know, the RAC program is now national. In a conference call, CMS stated that the RAC contractors would start with automated reviews, such as duplicate payments, and do more intensive reviews that require record review later.

The RAC contractor receives paid claims data, analyzes it with their own proprietary software and will issue refund demands. Recently I saw two coding practices that I think would be caught by this automated review:

**The practice had their computer system add modifier 25 to all claims. This would raise a red flag that the group doesn't know the rules.

**Always billing a low level visit (99212) with all wound care procedures. This doesn't fly under the radar, because it's a low level visit, but rather, gets a payer's attention because of the high volume of 99212s.

RAC tactics

Of course they are going after the automated errors first- easy start up money. But then again if you bill for performing a hysterectomy on a male or doing a colonoscopy on a dead patient, you deserve to be caught.

The hospitals are going to have a much tougher time with their medical appropriateness audits- the "retrospectoscope" shows a much clearer picture than when the patient is actually seen and convincing the auditors of that will be tricky. And if you really, really understand the OPO vs. inpatient rules, you are the only one- even the QIO's do not agree on the rules.

Adding a -25 to all claims sounds like a mandate from a physician- "I am sick of not getting paid- just put a 25 on everything." "Yes, Doctor."

Why bill a 99212? Do you really think they are going to see that and say "Hey look- these guys are undercoding! Let's go give them the bucket of money they really earned!"

Take a seminar and learn to code properly. After a session with Betsy, I increased my 99214's by 10-15%- I was doing the work but not documenting what I thought and did. Without even touching a patient I can get 5-6 bullet points on an exam that I was neglecting (rash, joints, bruising, gait, orientation, edema) and all my counseling is now being "appreciated" by the auditors in my documentation. And love that 99354- prolonged service code!

RAC tactics

Thanks for the kind words!

There's nothing that's as much fun as speaking to a few hundred doctors interested in coding!

Betsy