RAC Issues: Proposed and Approved

On December 12, 2017, CMS posted the second, monthly list of review topics that have been proposed, but not yet approved, for RACs to review. These topics are listed, on a monthly basis, on the CMS RAC Provider Resources page. For the month of December there is only one topic proposed for RAC review affecting DMEPOS suppliers, listed below.

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

State(s)/MAC regions where reviews will occur: All states

Review type: Complex review

Provider type: DME Supplier

Affected code(s):

  • E0464 – Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
  • E0465 – Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

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 2/8/2017
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

Approved issues can be found on Performant Recovery’s website, here.

Want to feel confident that the ventilators you are providing meet coverage criteria? Sign up for our ventilator prescreen program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the ventilator meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our ventilator prescreen program.

Be prepared before you receive a RAC audit. Ensure that your ventilator program is in compliance with Medicare regulations. Contact us to find out more information!If you receive a RAC audit

 

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.