Use LCDs, NCDs, to Steer Clear of Audits

Connolly, the Medicare recovery auditor for Texas, has added a new issue to the list of those the Centers for Medicare & Medicaid Services (CMS) has approved it to audit. (Note the issues on this list affecting Texas are those with a States column notation of "Region C," "Novitas Region C," or "Texas.")

The new issue is: Surgical Management of Morbid Obesity-Medical Necessity-Inpatient (C003292013). Medicare considers this type of surgery reasonable and necessary only if the patient meets the definition of morbid obesity  a body mass index >= 35  and comorbid conditions exist as outlined in the national coverage determination (NCD) and local coverage determinations (LCDs).

Remember: Your best line of defense against an RA audit on this issue or any others on the CMS-approved audit list  or against rejected Medicare claims in general  is familiarity with CMS NCDs and Novitas LCDs to make sure you meet the coverage criteria for services and procedures. CMS' new Medicare Coverage Database webpage makes it easy to search both national and local coverage documents, including retired LCDs.

 You also should watch for LCD updates and the opportunity to make comments. For example, currently, the following is posted for comment and will become effective on Dec. 5, 2013:  DL32619-Bariatric Surgical Management of Morbid Obesity.

 Need to Appeal an RA Audit?

Refer to CMS' four-page brochure (PDF) that summarizes the recovery audit process, with a flow chart and links for more information. If you receive an overpayment determination letter from Connolly, review your options. If you decide to appeal, go to Novitas' online Appeals Center to find the forms, process, timeframes, and requirements.

 TMA Can Help  

  •  TMA's popular annual Medicare update seminar will tour the state Nov. 5-Dec. 4, and for the first time, will be available as a live webcast, on Nov. 5. Led by TMA staff experts, this new seminarwill help you take Medicare head on in 2014 as it guides you through appeals, audits, common errors, participation options, incentives, documentation, the new Novitas website, and much more. Register today for a live seminar or the webcast.
  • Learn how to conduct a self-audit, what to do with your findings, and how to obtain buy-in for corrective actions in TMA's on-demand webinar, Avoiding RAC Audits.
  • Contact TMA Practice Consulting at (800) 523-8776 to schedule a Coding and Documentation Review.

Revised Oct. 24, 2013

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