CMS Approves More E&M Services for Automated Reviews

Lack of Appropriate Modifiers Cited

The Centers for Medicare & Medicaid (CMS) approved the RAC for Region D (HDI) on March 31, 2010, for two new issues involving Automated Review of Medicare claims including the use of several specific Modifers for Evaluation and Management (E&M) service codes.  HDI posted those news issues on their Approved Issues page on Friday, May 28.

Modifier Issues

Two issues were added to the Approved Issues list for HDI:

Co-Surgery not billed with Modifier -62 -- When two surgeons perform surgery on the same patient, both surgeons must add Modifier -62 to their billing. A bill without the modifier is considered an improper payment and will be recouped.

Global Days -- Most surgical procedures include pre-operative and post-operative E&M services, referred to as "Global Days," and have specific codes assigned to them depending when they occur, relative to the day of the procedure. Bills involving E&M services performed during the global period but unrelated to the surgical procedure must be submitted with appropriate modifiers, -24, -25 or -57.

Automated Reviews by the RAC

Both issues have been approved for Automated Review. An Automated Review occurs when a RAC makes a claim determination at the system level without a human review of the medical record. All the RACs are equipped with software "scrubbers" -- software programs that search for and identify suspect claims within the vast database of Medicare claims.

Upon identifying a suspected improper payment, however, the RAC must meet two very specific conditions before they can declare and recoup for an improper payment, according to the Statement of Work (SOW). Those conditions are:

1. there is certainty that the service is not covered or is incorrectly coded, AND
2. a written Medicare policy, Medicare article or Medicare-sanctioned coding guideline (e.g., CPT statement, CPT Assistant statement, Coding Clinic statement, etc.) exists.

An Exception Cited

There is an important exception mentioned in the SOW:

EXCEPTION: If the RAC identifies a “clinically unbelievable” issue (i.e., a situation where certainty of noncoverage or incorrectly coding exists but no Medicare policy, Medicare articles or Medicare-sanctioned coding guidelines exist), the RAC may seek CMS approval to proceed with automated review.  Unless or until CMS approves the issue for automated review, the RAC must make its determinations through complex review.

Emphasis is original.

Read more about Automated Reviews in the SOW, posted in our Documents Section.

Find links to all the RAC New Issues Pages in our Documents Section.