Coding Strategy

RACs are just another tool in the government’s arsenal to collect improper payments.

You’ve got so many compliance acronyms flying at you every day that you may not be able to differentiate your RAC from the OIG. Know these quick facts about RACs to stay better informed.

• Recovery audit contractors (RACs) detect and correct past improper payments so CMS and the MACs can prevent such problems in the future
• RACs are hired as contractors by the government, and they can can collect “contingency fees,” which means that they get a percentage of the amount that they recover from providers who were paid inappropriately The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007
• Between 2005 and 2008, RACs involved in the original demonstration project recovered over $1.03 billion in Medicare improper payments, but referred only two cases of potential fraud to CMS, according to a February OIG report on the topic, which noted that “because RACs do not receive their contingency fees for cases they refer that are determined to be fraud, there may be a disincentive for RACs to refer potential cases of fraud.”
• Unlike RACs, the OIG is a government entity. Although the OIG also performs reviews and audits and seeks improper payments, the OIG does not collect contingency fees.

For more on the RAC program, visit www.cms.gov/rac.

@ Part B Insider. Editor: Torrey Kim, CPC

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Image by Stephen Woods.

You have two options depending on how the physician performed the procedure.

Question: Our orthopedist administered a hip injection under fluoroscopy. Can I report both codes?

Wyoming Subscriber

Answer: You can code both the injection and fluoroscopy, but the correct choices depend on how your physician completed the procedure.

Option 1: If your orthopedist injected radiopaque dye and performed the arthrography concurrently, code the procedure with 27093 (Injection procedure for hip arthrography; without anesthesia).

Option 2: If he completed the guidance and injection as separate procedures, submit 20610 (Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) for the injection. Include 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) for the fluoroscopic guidance.

Remember to append modifier 26 (Professional component) to 77002 because your physician performed the service but doesn’t own the fluoroscopy equipment.

SI change: If the physician injects the sacroiliac joint instead of the hip joint, choose either 20610 (Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) or 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid).

@ Orthopedic Coding Alert. Editor: Leigh DeLozier, CPC

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If you have a question, be sure to ask your physician.

Question: A patient reports to the ER at 8 a.m. on a Sunday morning. He reports a horrible toothache that started on Friday; he says he planned to “tough it out” over the weekend and see his dentist Monday, but the pain was too severe; he reports 10 on a 10-point pain scale. The ER physician performs an “inf. Aveo block,” according to the notes. What condition do the notes reflect, and how should I code this scenario?

Massachusetts Subscriber

Answer: You should double-check with the physician before filing the claim, but the shorthand appears to indicate that he performed an inferior Aveolar block, which is a type of dental block. If the physician confirms this procedure, report the following:

• 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) for the block
• 525.9 (Unspecified disorder of the teeth and supporting structures) appended to 64400 to represent the patient’s condition.

@ Emergency Department Coding Alert, Editor: Chris Boucher, CPC

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The incorrect Fee Schedule calculation could have cost your practice precious dollars.

Earlier this month, President Obama helped you avert a 21 percent pay cut by signing the “Continuing Extension Act of 2010” — but one MAC let several claims slip through the system using the discounted payment formula, and the payer is in the process of correcting its error.

Just before the president signed the law on April 15, MACs had been holding all claims for dates of service between April 1 and April 14. Even though the pay freeze was retroactive to April 1, some practices…… worried that their MACs might process claims using the 21 percent reduced fee during the period on April 15 after the claims hold expired but before the president signed the law.

In one case, those fears may have been warranted.

According to an April 26 notification from Highmark Medicare Services (a Part B payer in five states), several claims for dates of service on or after April 1 and received between April 1 and April 7 “potentially paid at the incorrect -21 percent reduced fee schedule.”

Highmark indicated that it had “identified the universe of claims impacted by the use of the incorrect fee schedule,” and made a mass adjustment. “Our goal is to have initiated 95 percent of all adjustment claims by Wednesday, May 5th,” Highmark indicated, promising to provide additional updates as the adjustments are made.

For more on this issue, visit www.highmarkmedicareservices .com.

Get the latest provider news by subscribing to the Part B Insider. Editor: Torrey Kim, CPC

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Did you factor in a foreign body removal code?

Question: During an open hernia repair for a reducible umbilical hernia, the surgeon finds a sizeable gallstone embedded in the omentum extending into the preperitoneal fat. The surgeon excises the gallstone granuloma with cautery. Patient history indicates cholecystectomy eight years ago. What are the correct ICD-9 and CPT codes?

Utah Subscriber

Answer: The proper procedure code for this scenario is 49585 (Repair umbilical hernia, age 5 years or older; reducible). If the gallstone resection represents a significant amount of extra time and effort, modifier 22 (Increased procedural services) would be appropriate.

Watch out: You should not report the omentum gallstone resection (49255, Omentectomy, epiploectomy, resection of omentum [separate procedure]) in addition to the 49585 hernia repair. As a designated “separate procedure” code, you should only list 49255 if it is the only procedure the surgeon performs at the site. Because you indicate that the gallstone is imbedded in the omentum and extends only partially into the peritoneum, you should not code the service as a peritoneal foreign body removal (49402, Removal of peritoneal foreign body from peritoneal cavity).

As to ICD-9 codes, the documentation can make a big difference. If your surgeon indicates that he thinks the gallstone was dropped and left in the omentum during the previous surgery, you should consider it a foreign body left during surgery and code 998.4 (Foreign body accidentally left during a procedure). Otherwise, the best diagnosis choice is 568.9 (Unspecified disorder of peritoneum). Report the umbilical hernia as 553.1 (Umbilical hernia).

@ General Surgery Coding Alert, Editor: Ellen Garver, CPC

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