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In the March 26, 2013, posting for RAC Region A Performant, the drug code J9055 Cetuximab, an epidermal growth factor inhibitor used for metastatic colorectal cancer and some head and neck cancers, now impacts the following states: DE, MD, NJ, PA, and DC. This semi-automated audit shows there is potential for incorrectly billing this drug with diagnosis codes that do not support medical necessity. The recoupment will occur when documentation is not received from the provider within the 45-day response period.

A semi-automated review drills into your claim data and profiles your claim, much as the credit card companies do when you make large purchases in one state and then make more purchases in another. Now that you are on the RAC semi-automated radar, it will send you an “informational” letter that looks just like all the other letters you get for audits. This one has “informational” marked on it.  You will have only 45 days to file more clinical documentation to overturn their decision, and the RAC has 60 days to either reverse its finding or forward the file to the MAC for recoupment.

Getting the correct diagnosis is key, as well providing the supporting clinical documentation for this semi-automatic review to justify your claim.

Note: This drug code represents 10 mg per unit; therefore, when billing for this drug, bill one (1) unit for every 10 mg per patient.

Other RAC issues for the week of March 25th – 29th, 2013:

RAC Region A Performant

Physician/Non Physician Practitioner Claim Types

  • Hyaluronic Acid – J12 Potential incorrect billing occurred for hyaluronic acid claims billed with an ICD-9-CM code that does not support medical necessity, according to existing Medicare policy, FDA labeling, accepted guidelines, approved compendia, or other Medicare rules and regulations. Payments will be recouped when no additional documentation is received from the provider for complex review within the 45-day response period.

DME Claim Types

  • Patient Lifts – DME Jurisdiction A Potential incorrect billing occurred when claims for patient lifts were billed without an indication supporting Medical Necessity as described in the Medicare National Coverage Determination, IOM Publication 100-03, Chapter 1, Part 4, Section 280.1, and the NHIC Local Coverage Determination (LCD) L5064 and related article (A23657).

RAC Region D HDI

ASC Claim Types

  • Injections Not Supported by Diagnosis – J1 Injections of the Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton’s Neuroma not supported by Diagnosis for J1.

I’ll return next Tuesday with another edition of “Drill Down.” You can also hear me next Tuesday on Monitor Monday, 10 a.m. easrtern.

About the Author

Dr. Margaret Klasa is the medical director for Context4Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding with an emphasis on clinical and regulatory guidelines for Medicare and Medicaid and commercial payers.

Contact the Author


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