Proposed RAC Issues for December 2017

CMS has added to their monthly list of proposed RAC topics for review. As indicated, these topics are those that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page. For the month of December there is only one proposed for RAC review affecting DMEPOS suppliers, listed below.

NOTE: The November proposed topic, Respiratory Assist Devices, was proposed on November 13, 2017 and added to the RAC’s Approved Issues list on December 17, 2017.

Ventilators Subject to DWO requirements on or after January 1, 2016

Description: Documentation will be reviewed to determine if ventilators meet coverage criteria and/or are medically reasonable and necessary.

Review type: Complex review

Affected code(s): E0465, E0466

Applicable policy references:

  • Social Security Act, Section 1833. [42 U.S.C. 1395l] (e)
  • Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries
  • 42 C.F.R. sections 405.980 (b) & (c) and section 405.986
  • 42 CFR 424.57(a)(12)
  • Title XVIII, Social Security, §1862(a)(1)(A)
  • CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9
  • CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20
  • CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1
  • CMS Policy Article A55426 for Standard Documentation Requirements for All Claims

Currently CMS has approved the following issues for the RAC to review:

Complex Date Posted
Respiratory Assist Device 12/17/2017
PAP Devices for the treatment of OSA 9/19/2017
Spinal Orthoses 8/2/2017
Chest Wall Oscillation Devices 2/8/17
Tracheotomy suction catheters, suction pumps, catheters and other supplies 2/8/2017
AFO/KAFO 7/7/2017
Negative Pressure Wound Therapy Pumps 4/28/2017
PMDs not subject to PA Demonstration 6/6/2017
Nebulizers 4/14/2017
Osteogenesis stimulators 2/14/2017
Group 2 Support Surfaces 2/15/2017
Blood Glucose Monitors with Integrated Voice Synthesizer 5/12/2017
Enteral Nutrition Therapy 5/11/2017
Automated Date Posted
CPAP without OSA Diagnosis 9/8/2017
Nebulizers 2/2/2017
Hospital beds with mattresses billed with Group I or Group II support surfaces 4/12/2017
Group 3 PWC Underpayments 5/17/2017
DME while beneficiary is in an inpatient stay 2/16/2017
Spring Powered Devices Billed for >1 in a 6 Month Period 1/5/2017
CPM Billed without Total Knee Replacement 2/2/2017
Glucose Monitor 1/5/2017
Multiple DME Rentals in one month 3/31/2017

If you receive a RAC audit, The van Halem Group can help! Contact us to find out more information!