Region D: RAC Approved Issues by State

Region D: RAC approved issues by state

(Updated 3-1-11)

State / Region/ RAC / Approved Issues (Claim type)
Alaska / Region D/HDI / For Part A claims:
·  SNF Consolidated Billing
·  Hospice Related Services – B
·  Acute Hospital Readmissions without condition code B4 or 42
·  Incorrect patient status-IRF
·  Minor surgery and other treatment billed as an inpatient stay
·  Acute inpatient hospitalization – infections
·  Acute inpatient hospitalization - musculoskeletal disorders
·  Acute inpatient hospitalization - respiratory conditions
·  Acute inpatient hospitalization - neurological disorders
·  Gastrointestinal disorders billed as an inpatient stay
·  Nervous system disorders billed as an inpatient stay
·  Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
·  OP services within 72 hours of admit
·  Neulasta (HCPCS code J2505)
·  Medically unlikely edits
For Part B claims:
·  Global vs. TC/PC
·  Facility vs. Non-Facility Reimbursement (Inpatient)
·  NCCI Edits
·  Hospice Related Services – B
·  TC of Radiology
·  Not a New Patient
·  Medically unlikely edits
·  CSW During Inpatient
·  Ambulance during inpatient
·  Ambulance SNF to SNF transfer (NN Modifier)
·  Date of death
·  Part B duplicates - automated review
·  Co-surgery not billed with modifier 62
·  Global days
·  Anesthesia care package E/M services
·  Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
·  Procedures performed during the global period of other procedures
·  Multiple surgery reduction errors: single line modifier 51 underpayments
·  Multiple surgery reduction errors - underpayments
·  Multiple surgery reduction errors – overpayments
·  Wheelchair seating, mutually exclusive codes
·  AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
·  Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit
·  Once in a Lifetime
·  Excessive Units—Untimed Codes
·  Excessive Units—Blood Transfusions
·  Excessive Units—Bronchoscopy
·  Excessive Units—IV Hydration
For inpatient hospital claims:
·  Inpatient admissions without a physician's inpatient admit order
For DME claims:
·  Urological bundling
·  Wheelchair Bundling
·  Knee Orthotic Bundling
·  PEN supplies more than one time a day
·  Infusion Pump Denied/Accessories & Drug Codes should be denied
·  DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay
·  SNF Consolidated Billing
·  A4221 Excessive Units
·  Prosthetic Bundling
·  DME while in Hospice
·  Medical Supplies and Home Health Consolidated billing
·  Date of Death-DME
·  Medically unlikely edits
·  DME duplicates
·  CPM device after three weeks
·  Complex review of lower limb prosthetics
·  Therapeutic footwear utilization
·  Mobility durable medical equipment paid after claim patient lift paid
·  Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD) accessories
·  Overutilization of nebulizer medications
·  Lower limb suction valve prosthetics
·  Breast prosthetics allowed one a side
·  Transcutaneous electrical nerve stimulators (TENS) supplies bundling
For non-medical necessity DRG-validation inpatient claims:
·  Amputations (MS-DRGs 239-241, 255-257, 474-476, 616-618)
·  Blood & immunological procedures (MS-DRGs 799, 800, 801, 802, 803, 804)
·  Burns (MS-DRGs 927, 928, 929, 933, 934, 935)
·  Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263, 264)
·  Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
·  Eye procedures(MS-DRGs 113-117)
·  Female reproductive system procedures (MS-DRGs 734-750)
·  Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)
·  Health status factors (MS-DRGs 939, 940, 941, 945-951)
·  Infection (MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869)
·  Kidney & urinary tract procedures (MS-DRGs 652-675 and 691, 692, 693, 694, 694)
·  Male reproductive system procedures (MS-DRGs 707-718)
·  Malignant breast disorders (MS DRGs 597, 598, 599)
·  Mental diseases & disorders (MS-DRGs 876, 880-887, 894-897)
·  Multiple significant trauma procedures (MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965)
·  Neoplasm (MS-DRGs 837-849)
·  Neoplasm surgery(MS-DRGs 837-849)
·  Nervous system procedures (MS-DRGs 020-033 and 037-042)
·  OR procedure unrelated to principal diagnosis (MS DRGs 981-989)
·  Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863)
·  Procedures for injuries (MS-DRGs 907, 908, 909)
·  Septicemia (MS-DRGs 870, 871, 872)
·  Skin graft & connective tissue procedures (MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581, 622-624, 901-905)
·  Spinal fusion (MS-DRGs 453, 454, 455, 456, 457, 458, 459, 460, 471, 472, 473, 490, 491)
·  Transplants (MS-DRGs 001, 002, 003, 004, 005, 006, 007, 008, 009, 010, 011, 012, 013)
·  Pregnancy, Childbirth & Peruperium (MS-DRGs 765, 766, 767, 768, 769, 770, 771, 774, 775, 776, 777, 778, 779, 780, 781, 782
·  Breast Procedures (MSDRGS 582, 583, 584, 585, 600, 601)
·  Ear, Nose, Mouth & Throat Disorders (MSDRGS 146-159)
·  Endocrine, Nutritional & Metabolic Procedures (MSDRGS 614, 615, 619, 620, 621, 625, 626, 627, 628, 629, 630)
·  Eye Disorders (MSDRGS 121-125)
·  Female Reproductive System Disorders (MSDRGS 754,-761)
·  HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977)
·  Infection, Other (MSDRGS 075, 076, 864, 865, 866)
·  Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906)
·  Male Reproductive System Disorders (MSDRGS 754-761) Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563)
·  Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607)
·  Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)
·  Incorrect patient status-acute
For medical necessity DRG validation claims:
·  DRG validation-cardiovascular, other (Medical necessity review may be performed for MS DRG 312 only)
·  DRG validation-musculoskeletal disorders (Medical necessity review may be performed for MS DRGs 551 and 552 only.)
·  DRG validation-blood and immunological disorders (Medical necessity review may be performed for MS DRG 811 only.)
·  DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS DRGs 253, 254, 291-293, 302, 308, 313-316 only.)
·  DRG validation-nervous system disorders (Medical necessity review may be performed for MS DRGs 056, 057 and 069 only.)
·  DRG validation-kidney and urinary tract disorders (Medical necessity review may be performed for MS DRGs 682-684 and 689 only.)
·  DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be performed for MS DRG 640 only.)
·  DRG validation-gastrointestinal disorders (Medical necessity review may be performed for MS DRGs 391 and 393 only.)
·  DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG 249 only.)
·  DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS DRGs 190, 191 and 192 only.)
·  DRG validation-cardiovascular procedures (253 and 254 only)
Arizona / Region D/HDI / For Part A claims:
·  SNF Consolidated Billing
·  Hospice Related Services – B
·  Acute Hospital Readmissions without condition code B4 or 42
·  Incorrect patient status-IRF
·  Minor surgery and other treatment billed as an inpatient stay
·  Acute inpatient hospitalization – infections
·  Acute inpatient hospitalization - musculoskeletal disorders
·  Acute inpatient hospitalization - respiratory conditions
·  Acute inpatient hospitalization - neurological disorders
·  Gastrointestinal disorders billed as an inpatient stay
·  Nervous system disorders billed as an inpatient stay
·  Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
·  OP services within 72 hours of admit
·  Neulasta (HCPCS code J2505)
·  Medically unlikely edits
For Part B claims:
·  Global vs. TC/PC
·  Facility vs. Non-Facility Reimbursement (Inpatient)
·  NCCI Edits
·  Hospice Related Services – B
·  TC of Radiology
·  Not a New Patient
·  Medically unlikely edits
·  CSW During Inpatient
·  Ambulance during inpatient
·  Ambulance SNF to SNF transfer (NN Modifier)
·  Date of death
·  Part B duplicates - automated review
·  Co-surgery not billed with modifier 62
·  Global days
·  Anesthesia care package E/M services
·  Practice expense (PE) relative value unit (RVU) increase for CPT code 93503
·  Procedures performed during the global period of other procedures
·  Multiple surgery reduction errors: single line modifier 51 underpayments
·  Multiple surgery reduction errors - underpayments
·  Multiple surgery reduction errors – overpayments
·  Wheelchair seating, mutually exclusive codes
·  AFO and KAFO custom fabricated versus prefabricated codes
For Part A outpatient and Part B claims:
·  Newborn Pediatric CPT Codes Billed for Patients Exceeding Age Limit
·  Once in a Lifetime
·  Excessive Units—Untimed Codes
·  Excessive Units—Blood Transfusions
·  Excessive Units—Bronchoscopy
·  Excessive Units—IV Hydration
For inpatient hospital claims:
·  Inpatient admissions without a physician's inpatient admit order
For DME claims:
·  Urological bundling
·  Wheelchair Bundling
·  Knee Orthotic Bundling
·  PEN supplies more than one time a day
·  Infusion Pump Denied/Accessories & Drug Codes should be denied
·  DMEPOS while patient is in a Covered Part A Inpatient Hospital Stay
·  SNF Consolidated Billing
·  A4221 Excessive Units
·  Prosthetic Bundling
·  DME while in Hospice
·  Medical Supplies and Home Health Consolidated billing
·  Date of Death-DME
·  Medically unlikely edits
·  DME duplicates
·  CPM device after three weeks
·  Complex review of lower limb prosthetics
·  Therapeutic footwear utilization
·  Mobility durable medical equipment paid after claim patient lift paid
·  Overutilization of positive airway pressure (PAP) and respiratory assist device (RAD) accessories
·  Overutilization of nebulizer medications
·  Lower limb suction valve prosthetics
·  Breast prosthetics allowed one a side
·  Transcutaneous electrical nerve stimulators (TENS) supplies bundling
For non-medical necessity DRG-validation inpatient claims:
·  Amputations (MS-DRGs 239-241, 255-257, 474-476, 616-618)
·  Blood & immunological procedures (MS-DRGs 799, 800, 801, 802, 803, 804)
·  Burns (MS-DRGs 927, 928, 929, 933, 934, 935)
·  Cardiovascular procedures (MS-DRGs 216-221, 228, 229, 230, 237, 238, 250, 251, 252, 263, 264)
·  Ear, nose, mouth & throat procedures (MS-DRGs 129-139)
·  Eye procedures(MS-DRGs 113-117)
·  Female reproductive system procedures (MS-DRGs 734-750)
·  Gastrointestinal disorders (MS-DRGs 368-395 and 432-446)
·  Health status factors (MS-DRGs 939, 940, 941, 945-951)
·  Infection (MS-DRGs 094, 095, 096, 853, 854, 855, 867, 868, 869)
·  Kidney & urinary tract procedures (MS-DRGs 652-675 and 691, 692, 693, 694, 694)
·  Male reproductive system procedures (MS-DRGs 707-718)
·  Malignant breast disorders (MS DRGs 597, 598, 599)
·  Mental diseases & disorders (MS-DRGs 876, 880-887, 894-897)
·  Multiple significant trauma procedures (MS-DRGs 955, 956, 957, 958, 959, 963, 964, 965)
·  Neoplasm (MS-DRGs 837-849)
·  Neoplasm surgery(MS-DRGs 837-849)
·  Nervous system procedures (MS-DRGs 020-033 and 037-042)
·  OR procedure unrelated to principal diagnosis (MS DRGs 981-989)
·  Postoperative or post-traumatic infection (MS DRGs 856, 857, 858, 862, 863)
·  Procedures for injuries (MS-DRGs 907, 908, 909)
·  Septicemia (MS-DRGs 870, 871, 872)
·  Skin graft & connective tissue procedures (MS-DRGs 463-465, 477-479, 500-502, 515-517, 573-581, 622-624, 901-905)
·  Spinal fusion (MS-DRGs 453, 454, 455, 456, 457, 458, 459, 460, 471, 472, 473, 490, 491)
·  Transplants (MS-DRGs 001, 002, 003, 004, 005, 006, 007, 008, 009, 010, 011, 012, 013)
·  Pregnancy, Childbirth & Peruperium (MS-DRGs 765, 766, 767, 768, 769, 770, 771, 774, 775, 776, 777, 778, 779, 780, 781, 782
·  Breast Procedures (MSDRGS 582, 583, 584, 585, 600, 601)
·  Ear, Nose, Mouth & Throat Disorders (MSDRGS 146-159)
·  Endocrine, Nutritional & Metabolic Procedures (MSDRGS 614, 615, 619, 620, 621, 625, 626, 627, 628, 629, 630)
·  Eye Disorders (MSDRGS 121-125)
·  Female Reproductive System Disorders (MSDRGS 754,-761)
·  HIV Infections (MSDRGS 969, 970, 974, 975, 976, 977)
·  Infection, Other (MSDRGS 075, 076, 864, 865, 866)
·  Joint Procedures (MSDRGS 461, 462, 466-470, 480-489, 492-494, 498, 499, 503-514, 535, 536, 906)
·  Male Reproductive System Disorders (MSDRGS 754-761)
·  Musculoskeletal Fractures (MSDRGS 495, 496, 497, 533, 534, 537, 538, 542, 543, 544, 562, 563)
·  Skin Disorders (MSDRGS 592, 593, 594, 595, 596, 602, 603, 604, 605, 606, 607)
·  Disorders Related to Injuries, Toxicity (MSDRGS 913, 914, 915, 916, 917, 918, 919, 920, 921, 922, 923)
·  Incorrect patient status-acute
For medical necessity DRG validation claims:
·  DRG validation-cardiovascular, other (Medical necessity review may be performed for MS DRG 312 only)
·  DRG validation-musculoskeletal disorders (Medical necessity review may be performed for MS DRGs 551 and 552 only.)
·  DRG validation-blood and immunological disorders (Medical necessity review may be performed for MS DRG 811 only.)
·  DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS DRGs 253, 254, 291-293, 302, 308, 313-316 only.)
·  DRG validation-nervous system disorders (Medical necessity review may be performed for MS DRGs 056, 057 and 069 only.)
·  DRG validation-kidney and urinary tract disorders (Medical necessity review may be performed for MS DRGs 682-684 and 689 only.)
·  DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be performed for MS DRG 640 only.)
·  DRG validation-gastrointestinal disorders (Medical necessity review may be performed for MS DRGs 391 and 393 only.)
·  DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG 249 only.)
DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS DRGs 190, 191 and 192 only.)
·  DRG validation-cardiovascular procedures (253 and 254 only)
California / Region D/HDI / For Part A claims:
·  SNF Consolidated Billing
·  Hospice Related Services – B
·  Acute Hospital Readmissions without condition code B4 or 42
·  Incorrect patient status-IRF
·  Minor surgery and other treatment billed as an inpatient stay
·  Acute inpatient hospitalization – infections
·  Acute inpatient hospitalization - musculoskeletal disorders
·  Acute inpatient hospitalization - respiratory conditions
·  Acute inpatient hospitalization - neurological disorders
·  Gastrointestinal disorders billed as an inpatient stay
·  Nervous system disorders billed as an inpatient stay
·  Kidney and UTI disorders billed as an inpatient stay
For Part A outpatient claims:
·  OP services within 72 hours of admit