CODING & COMPLIANCE

Blepharoplasty RAC Audits in the ASC

A Primer for Defense

BY RIVA LEE ASBELL

ASC RAC audits on blepharoplasty are coming your way. This review gives background information and some tips on how to handle your defense.

What Is a RAC Audit?

The Recovery Auditor Contractor (RAC) was the original name of this Centers for Medicare and Medicaid Services (CMS) outsourced program, which was subsequently changed to the Recovery Auditor program. However, it continues to be known as “The RAC Audits.” The program was established to identify and correct improper Medicare payments. The auditing contractors are paid on a contingency basis and are supposed to identify both overpayments and underpayments by Medicare Administrative Contractors (MACs) who are your claims processors. The states are divided into areas, shifting at times, under the jurisdiction of the companies identified on the map (Figure 1).

Figure 1
• Region A: Performant Recovery
• Region B: CGI Federal, Inc.
• Region C: Connolly, Inc.
• Region D: Health Data Insights, Inc.
Figure courtesy of the American Hospital Association. www.aha.org/advocacy-issues/rac/contractors.shtml

There are three types of audits: automated, semi-automated and complex. The automated audits are mostly data mining audits. For example, audits on office encounters coded as a “New Patient” that are based on the physician’s National Provider Identification (NPI) number. Claims warranting recoupment are sent directly to the MAC for withholding from your paycheck.

A semi-automated audit may be initiated by data mining and then a request for medical records may be initiated as well. Complex audits request medical records from the outset and are reviewed by an auditor and a determination is made that may result in direct withholding from your Medicare payment.

What is the Blepharoplasty RAC About?

Each Recovery Auditor keeps a list of issues posted on their website that includes the class of provider being audited (physician, ASC, inpatient hospital, and so on). The blepharoplasty audits are listed as pertaining both to the physician and the ASC.

The current audits are complex and focus on blepharoplasty and ptosis surgery regarding whether it is cosmetic or functional. Criteria that the RAC uses will be listed in your MAC’s Local Coverage Determination (LCD). A typical description is shown from Performant Recovery:

“Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. When blepharoplasty repair is done for cosmetic purposes it does not meet the criteria of the functional visual impairment parameters and is considered not reasonable and medical necessary and therefore will denied [sic].”

Consider this: How is the ASC going to prove that the case was functional? ASCs generally keep medical records and not medical necessity/chart documentation records.

What Chart Documentation Should the ASC Keep?

Many ASCs aren’t in the habit of keeping physician chart documentation as part of the ASC permanent chart documentation. Rather, they’re deeply concerned and occupied with meeting Medicare’s Conditions of Coverage. Now is the time for a paradigm shift. As I write this, I’m receiving calls from clients who are preparing copies of their records to send off to a hospital or ASC to assist in their audit record requests. This after-the-fact gathering of information isn’t the same as the ASC having its own documentation preoperatively — otherwise, how could the ASC know if the case was cosmetic versus functional going forward? All the inherent billing issues, particularly charging the patient versus billing Medicare for the surgery, the facility fee and the anesthesia fees need to be decided before the surgery is performed, not afterward.

Suggested list of documents for the ASC chart

• Activities of Daily Living Form (ADL) (Figure 2)

Figure 2

• Blepharoplasty or Eyelid Ptosis or Brow Ptosis Checklist (Figure 3)

Figure 3

• Physician notes of the visit when surgery was scheduled and that document the patient’s problems that render the surgery functional

• Visual Fields showing a decrease with eyelids in normal position compared to position when taped up (per LCD) (as mandated by your MAC)

• Photographs (as mandated by your MAC)

What Else Should We Do?

• Outside Help. Consider hiring an attorney or consultant to help you prepare a summary letter of defense. In any event, prepare a letter that’s clearly dated and succinctly and thoroughly presents your case and rationale.

• Use Checklists. Use the checklists provided here after the summary in your response package. It will show that the requirements of the LCD have been met. Use the checklists in the ASC as well, to make sure the case is properly documented as functional.

• ICD-10-CM. Start your preparations and training now so you’ll be ready for proper diagnosis billing (For functional cases, the diagnosis should be dermatochalasis).

• LCDs. Have your surgeons, as well as you and your staff, read your MAC’s LCD on blepharoplasty, ptosis and brow lift. Don’t have one? Use one from Wisconsin Physician Services or National Government Services, and be sure to read the new LCD from Novitas-Solutions if that’s your MAC. This is a drastic revision and I would continue to perform visual fields even though they may not require it, because it’s your first line of defense for establishing that the case was functional.

• Physician Protocols. Please make sure your surgeons are following the same documentation procedures as you. ■