Healthcare Coding and Documentation 2011 Update - Part 4

For the most current information, view the Healthcare Coding and Documentation 2012 Update 


RAC Audits – Physician & Hospital 

RAC Audits – Region A Outpatient Hospital - Physician 

  • Untimed Codes
    • Certain untimed codes are billed for more than one unit
      • i.e. Physical Therapy
  • Newborn/Pediatric Codes
    • Patients that exceed the age limit defined by CPT code
  • Global Surgery
    • Pre- and Post-Operative visits
  • New Patient Visits
    • Guidelines for a new patient
      • New to practice
      • Has not been seen in practice for 3 years
  • Technical Component of Radiology
  • Neulasta
    • Drug that reduces risk of infection in cancer patients
      • Commonly reported with a chemotherapy drug administration code rather than a therapeutic administration code which creates an overpayment
  • Global Billing of Radiology or Diagnostic Tests in Facility Setting
  • Add-On Codes
    • Add-on code reimbursed when primary procedure either was not billed or not paid
  • NCCI Edits
  • Duplicate Claims
  • IV Hydration
    • When billed for more than one unit per date of service
  • Once in a Lifetime
    • i.e. Removal of organs; genetic testing; dialysis training etc.
  • Bronchoscopy Services
    • When billed for more than one unit per date of service
  • Global vs. TC/PC Split Reimbursements
    • Reimbursement for global and then additional reimbursement for TC or PC

RAC Audits – Region A Inpatient Hospital

  • MS-DRG Validation –
    • Currently Medical Necessity Excluded
      • Tracheostomy
      • Coronary Bypass, Cardiac & Cardiac Valve Procedures
      • Extensive & Non-Extensive OR Procedures
      • Joint Disorders
      • Major Chest Procedures
      • Major Large & Small Bowel Procedures
      • Hip & Femur Procedures
      • Intracranial Hemorrhage or Cerebral Infarction
      • Pulmonary Edema & Respiratory Failure
      • Ventilator Support of 96+ Hours
      • Craniotomy & Endovascular Intracranial Procedures
      • Excisional Debridement
      • Severe Sepsis
      • Complications of Cholecystectomy
      • Seizures
      • Lysis of Adhesions
      • Pathological Fractures
      • Cardiac Defibrillator
        • 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 contained in the beneficiary's medical record
  • DRG Coding and Medical Necessity Validation
    • Diseases of Blood, Blood Forming Organs & Immunological Disorders
      • Currently for MS-DRG 811
        • Red Blood Cell Disorders with MCC
    • Endocrine, Nutritional & Metabolic Disorders
      • Currently for MS-DRG 640
        • Nutritional & Miscellaneous Metabolic Disorders with MCC
    • Nervous System Disorders
      • Currently for MS-DRG’s 056 & 057
        • Degenerative Nervous System Disorders with MCC
        • Degenerative Nervous System Disorders w/o MCC
    • Musculoskeletal Disorders
      • Currently for MS-DRG’s 551 & 552
        • Medical Back Problems with MCC
        • Medical Back Problems w/o MCC
    • Gastrointestinal Disorders
      • Currently for MS-DRG’s 391 & 393
        • Esophagitis, Gastroenterology & Miscellaneous Digestive Disorders with MCC
        • Other Digestive System Diagnoses with MCC
    • Kidney and Urinary Tract Disorders
      • Currently for MS-DRG’s 683 & 684
        • Renal Failure with CC
        • Renal Failure w/o MCC
    • Respiratory
      • Currently for MS-DRG’s 190, 191 & 192
        • COPD with MCC
        • COPD with CC
        • COPD w/o CC and MCC
    • Cardiovascular Procedures
      • Currently for MS-DRG 249
        • Percutaneous Cardiovascular Procedure with Non-Drug Eluting Stent w/o MCC
  • IPPS Hospital to Hospital Transfers
    • Per diem rate should be paid for transferring hospital
    • Full MS-DRG payment to final discharge hospital
    • Validating that both hospitals don’t receive full MS-DRG payments


Contact Information

Steven Bisciello, MBA
Supervising Consultant, Healthcare Services Group  

EisnerAmper LLP is an independent member firm of PKF International Limited


The material contained in this presentation is for general information and should not be acted upon without prior professional consultation. 



Have Questions or Comments?

If you have any questions about this media item, we'd like to hear your opinion. Please share your thoughts with us.

Contact EisnerAmper

* Required