Connolly Healthcare, the Review Audit Contractor (RAC) for Texas, has posted the audit issues that have been approved by CMS on the Connolly website.
While the audit issues listed were approved for the State of South Carolina, the issues provide valuable information for Texas health care providers. It can be anticipated that audit issues that have been approved for one state will also form the basis for audits in other states. These audit issues will form the basis for automated audits in which the RAC may make a determination of overpayment based on database review without requesting medical records.
RACs may use automated review (where no medical record is involved in the review) only in situations where there is certainty that the claim contains an overpayment. Automated review must:
a) have clear policy that serves as the basis for the overpayment ("clear policy" means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will ALWAYS be considered an overpayment)
b) be based on a medically unbelievable service
c) occur when no timely response is received in response to a medical record request letter
The audit issues specify CPT codes that will be the target of audits and identify the particular issues that will be audited. For example, with regard to blood transfusions, CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one per session, regardless of the number of units transfused on that date of service. Providers may use this information to perform self audits, and, if appropriate, to refund overpayments if multiple blood transfusions were billed on the same day. Further, providers can use this information to review and, if necessary, to modify their billing practices so that future bills will not compound any prior billing errors.
The Connolly website should be monitored periodically for updates to the approved audit issues. If you have any questions regarding this e-Alert, please contact Carla Cox at 512.236.2040 or cjcox@jw.com.
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