Both the Department of Justice (DOJ) and the Recovery Audit Contractors (RAC) are focusing investigations on Medicare billing for implantable cardiac defibrillator (ICD) surgery. The reimbursement rate for ICD surgery is one of the higher dollar Medicare Severity Diagnosis Related Groupings (MS-DRG). The DOJ’s investigation is focusing on both medical necessity and MS-DRG coding validation issues, while the RACs are currently only conducting MS-DRG validation reviews. According to the CMS national coverage determination (NCD), Medicare pays for ICD implantation for eight specific conditions. However, there are many circumstantial limitations to coverage in these conditions that often lead to CMS not covering the implantation. For example, the beneficiary must not have had an acute myocardial infarction within 40 days prior to surgery. If a hospital being investigated by the DOJ performed the implantation despite this condition, the DOJ is requiring them to justify why they thought the surgery was medically necessary. The DOJ is sending out document production requests, requesting all documents related to ICD implantation coding, billing, payment, reimbursement, payment denials and ICD-related appeals by all payers. Additionally, RACs are conducting coding and validation reviews of MS-DRGs related to ICD surgery. When conducting validation reviews, the RACs are looking at the beneficiary’s medical record, specifically the diagnostic and procedural information and discharge status, to determine whether the ICD surgery MS-DRG code listed is supported by the proper documentation.Consider yourself warned, criminals.
Remember that malpractice litigation we were worried about? What were we thinking?
Those were the good ol' days.
Reference: “Justice Dept. Investigates Hospitals for Cardiac Billing in New Spin on RAC Risk.” Report on Medicare Compliance Vol. 19, No. 15. 26 Apr. 2010; 1, 5.