Gastroenterology Coding Alert

Question: We haven't been keeping up with what the recovery audit contractors (RACs) are reviewing right now – are there any that impact gastroenterology at the moment?

Codify Subscriber

Answer: Yes. On Dec. 12, Part B RAC Cotiviti announced that it would be reviewing "E/M codes billed within a procedure code with a zero-day global period (endoscopies or minor surgical procedures." If you do report a procedure that has a zero-day global, keep in mind that the procedure code already includes preoperative and postoperative E/M services, and a separate E/M should therefore not be reported.

Background: RACs are independent contractors that data-mine Medicare claims, review them for errors, and collect contingency fees based on the amounts they recover. Because of how they are paid, RACs are incentivized to go after coding and billing errors that are so common and widespread that they will be paid handsomely for discovering (and recovering) overpayments.

Currently, there are four RAC regions of the United States. Generally, Performant Recovery, Inc. reviews providers in the northeastern U.S., HMS Federal Solutions handles the west, and Cotiviti covers much of the midwestern and southeastern parts of the country.

Resource: Go to this CMS map to find your RAC region and the RAC assigned to your region: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Medicare-FFS-RAC-map-November-2016-clean.pdf.

On their web sites, the RACs disclose issues that CMS has approved them to audit. Here are the links to each RAC's "audit issues" page, which contain details about what the RAC is currently looking for.

Performant: https://performantrac.com/audit-regions/region-1/
HMS: https://racinfo.hms.com/Public1/NewIssues.aspx
Cotiviti: http://www.cotiviti.com/healthcare/who-we-serve/cms-approved-issues.

Similarly, Anthem Blue Cross in some of its service areas are reducing the E/M payment when reported with modifier 25 the same day as procedures. GI societies are protesting this policy, since the fee schedule elements of an E/M and procedure service do not overlap.