How to Bill for Renal and Urinary Tract Disorders and Avoid RACs

A recent Medicare Learning Network Matters (pdf) report informed hospitals how to bill for renal and urinary tract disorders in Medicare beneficiaries.

Recovery Auditors, previously known as Recovery Audit Contractors, complete medical necessity reviews of renal and urinary tract disorders. When RACs find the medical necessity for inpatient admissions of these conditions is not supported, those claims are then identified as overpayments.

CMS has given hospitals the following guidance on how to avoid these types of billing and coding problems associated with renal and urinary tract disorders:

•    The type of bill on the claim must match the physician order. For example, if the physician orders observation and there is no inpatient order, hospitals must bill it as outpatient.

•    Focus on the observation orders. There are several stipulations, especially for observation moving to inpatient, so hospitals must be certain the inpatient admission is medically reasonable and necessary.

•    If inpatient is ordered for these services and the hospital wants to change the patient to observation, this can be done using condition code 44 if the practitioner responsible for the patient's care agrees to the change and the patient is notified prior to discharge. Patients must be notified of this change.

•    Observation is a set of services provided to determine if the patient requires to be admitted to the hospital — it is not a status.

•    No changes to a patient's status may be made after the patient has been discharged.

More Articles on RACs:

The Uninsured and Net Returns: Q&A With DeKalb Medical CFO Diane Harden

Medicare RACs Collected $1.27B in Overpayments Since 2009

5 Tips for an Effective RAC Appeals Process

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