News Alert: Ventilators and Home Health Proposed RAC Targets

New RAC issues proposed for auditing appear to baffle the author

As promised, the Centers for Medicare & Medicaid Services (CMS) has posted its December 2017 list of issues that are being considered for Recovery Audit Contractor (RAC) auditing. And as expected, a few of the proposed issues appear a bit baffling. The issues appear in bold below and my commentary follows.

Ventilators subject to detailed written order requirements used on or after Jan. 1, 2016: documentation will be reviewed to determine if ventilators meet coverage criteria and/or are medically reasonable and necessary. It is inconceivable to me that a patient would have a ventilator without the medical necessity for it; most people seem to prefer to breathe on their own. Now, do durable medical equipment (DME) providers have all the necessary paperwork with a detailed written order? That could certainly be an issue, and DME providers would be wise to start reviewing all their files and updating any necessary documentation.

Annual wellness visits (AWVs) billed within 12 months of the initial preventative physical examination (IPPE) or annual wellness examination (AWV). This is another issue that baffles me. Medicare regulations indicate that 11 months must have passed from the IPPE or AWV before another can be performed and billed. Determining whether those criteria were met is a simple process that the Medicare Administrative Contractors (MACs) should be able to perform with simple claim edits. Why would CMS agree to pay a contingency fee to a RAC when the MAC should be doing it for free?

Home health: medical necessity and documentation review. This is big. As we have discussed in numerous articles and on Monitor Mondays, the documentation requirements for home care can be daunting in the areas of homebound status, need for skilled care, and the face-to-face visit. I suspect the RACs will have a field day with this, and home health agencies will be overwhelmed with requests and denials.

Cardiac pacemakers. While this may seem like a basic medical necessity audit target, the request for approval is to audit cardiac pacemakers placed not only at hospitals, but also at ambulatory surgery centers (ASCs). Pacemaker placements are permitted at ASCs; the current volume is unknown to me. As with hospitals with elective or semi-urgent procedures, the key is to obtain the physician’s office notes to support medical necessity. Most hospitals have that process hardwired, but I am not sure if ASCs are used to RAC audits and have processes in place. Now may the time for them to start preparing.

Evaluation and management (E/M) same day as dialysis. This is another physician billing issue, and one that I suspect will not do much to help the RACs’ profits. Caring for patients on dialysis has a whole set of regulations, and the nephrologists I know are all very well-versed in the coding rules.

If any of these issues affect you, be sure to go to the link above and download the notice with all the affected codes, provider types, and applicable regulations. And if not, keep reading, because your turn is coming.  


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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