A listing of topics approved by the Centers for Medicaid and Medicare Services (CMS) for RAC (Recovery Audit Contractor) review was recently published. The list is notable primarily in its focus on “automated reviews.” This means billing errors should be detected by looking at data on the claims forms and on Medicare data bases, without evaluating medical necessity. The take-away point is that providers and suppliers can encounter RAC denials on some rather technical aspects of medically necessary services.

The largest category of audit activity is “DRG (Diagnosis Related Group) Validation.” The audit will ensure that diagnostic and procedural information and the discharge status of the beneficiary as coded and reported by the hospital on its claim, matches both the attending physician description and the information in the beneficiary’s medical record. At this time, the RAC auditor will compare principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG to see if the assigned DRG is a fit with the diagnosis and procedure codes. These are data elements available to an auditor based on a filed claim.

Another large category for audit is for “bundled or consolidated items and services.” Where an item or service is included in a prospective payment – such as the DRG payment (hospital) or the resource utilization group rate (skilled nursing facility), separate claims should not be filed for those items. These can be identified by the RAC by comparing line items on a facility bill to Part B claims by outside suppliers.

Also of interest is the “Medically Unlikely Edit List.” A Medically Unlikely Edit (MUE) applies to all Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes that are billed above the maximum units of service that a provider would report for the same beneficiary, on same date of service and same provider.

These RAC Audit topics edits should inspire providers to pay attention to claims detail, and carefully note dates of service, units of service and definitions in billing codes relating to quantity or volume. For example, where a PT procedure is an untimed code, the provider should enter a one in the units billed column per date of service. If there is a dosage specified in a code, the units billed should represent the number of multiples of that dose administered, not the total number of milligrams, for example.

Going forward, it will be good policy to print out the definition of the codes used on a quarterly or semi-annual basis to ensure that there are no changes and that your billing is in accord with the definition. Be sure time and (a false sense of) familiarity are not dulling the sharpness of your coding compliance.