RAC Fact: Watch Out For Medicare’s Once-in-a-Lifetime Services

G0389 & the IPPE codes may be potential RAC targets

If you’ve been sweating it out, waiting for the recovery audit contractors (RACs) to announce where they’ll be focusing their audit efforts, you may or may not be relieved to know two RAC contractors have posted the areas they’ll have their eye on. More on that below …

Both lists include once-in-a-lifetime procedures, so named because you should report them just once in a beneficiary’s lifetime. Examples of once-in-a-lifetimes codes include G0402, G0403, G0404 and G0405 — HCPCS codes associated with the ‘Welcome to Medicare Visit,’ CMS explains on this info sheet.

Radiology Coders Beware: This ‘once-in-a-lifetime’ RAC focus could bring G0389 (Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm [AAA] screening) claims under scrutiny because the code represents a onetime AAA screening for Medicare patients referred following an initial preventive physical examination.

You can keep future claims clean by following the rules available. For example, for Medicare to cover the code, the patient must meet one of the following risk categories:

• has a family history of AAA

• is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime

• is a beneficiary who manifests other specified risk factors.

Keep in mind: “If you start looking at records retrospectively and find any problems, you create additional obligations on yourself to self-disclose any wrongdoing,” advises Michael F. Schaff, Esq., with Wilentz, Goldman and Spitzer in Woodbridge, N.J. And the CMS Web site notes that if your self-audit lead to refunds to your contractor for specific claims, “The RAC will be aware of the adjustment, but the refund does not preclude future review,” CMS notes in its RAC FAQ (ID 9503, searchable here.

Resources: The two contractors that have included one-time services on their review areas, are Connolly Consulting Inc., which handles Region C, and HealthDataInsights, for Region D.

Adapted from Radiology Coding Alert. Download your 2 FREE sample issues here.

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