Medicare Compliance & Reimbursement

Check out what’s on the radar screen of auditors.

The recovery audit contractors (RACs) are on the prowl and are targeting areas like cataract surgery and Mohs this year. Read on to find out how to avoid getting into hot water for these and other services.

Mohs Surgery

Region C RAC Connolly announced on Jan. 9 that it would begin auditing claims for Mohs surgery when the pathology is billed by a different provider, going back to dates of service from 2007 through the present.

Background: "Mohs micrographic surgery used for removal of complex or ill-defined skin cancer requires physicians to act in two integrated but separate capacities: surgeon and pathologist," the RAC says. "If either surgery or pathology is delegated to another physician who reports services separately, Mohs codes should not be reported since they include both the excision and the pathology services."

Tip: To report Mohs surgery appropriately, you need to verify that the physician not only removed the lesion (one layer may be enough) but also prepared sequential slides and rendered a diagnosis to each one completed at that stage. Because Mohs involves frozen section pathology, you will also likely see documentation that the physician immediately freezes the tissue samples after excising.

Cataract Extraction

Connolly also intends to aim its sights at cataract surgeries and whether they are being performed for medically necessary reasons.

Background: "Outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match the covered diagnosis codes in the LCD policies," Connolly notes.

Tip: Check your MAC’s LCD before you schedule the patient for surgery to ensure that your patient’s condition meets the requirements for the procedure. Many carriers, for instance, will cover cataract surgery for ICD-9 codes in the 366.00-366.9 (Non-senile cataract unspecified) range.

Transthoracic Echocardiography

DSC, the Region A RAC, announced on Jan. 11 that it would be reviewing claims for transthoracic echocardiography going back three years.

Background: "Incorrect billing occurred for claims billed with ICD-9 codes that are not listed by the LCD as medically necessary," DSC said in its announcement of the audit.

Tip: Most LCDs list dozens of codes that are payable for transthoracic echocardiography, but you must ensure that your patient’s condition is on the list before performing the procedure. If not, you won’t collect from Medicare for it.

Ultrasound Guidance

Part D RAC Health Data Insights began reviewing claims with excessive units of ultrasound guidance as of Dec. 11.

Background: "CMS developed medically unlikely edits (MUEs) to reduce the paid claims error rate for Part B claims," Health Data Insights noted. "Based on the MUE table, CPT code 76942 (Ultrasonic guidance for needle placement) is to be reported only once per beneficiary per date of service."

Tip: Report only one unit of 76942 for a single beneficiary on a single service date, or you’ll get a denial for the subsequent line items or units.