Posts Tagged ‘RAC/Recovery Audit Contractor’

Reminder: Medicare Has Approved The Auditing Of E/M Services… Be Sure Your Documentation Justifies The Code!

In Uncategorized on August 22, 2013 at 8:55 pm

Last September, the Centers for Medicare and Medicaid Services (CMS) approved Virginia’s Medicare Recovery Auditor (RAC) – Connolly – to begin conducting audits of coding for evaluation and management (E & M) services in physician offices, specifically CPT code 99215.  As such, the plan was for Connolly to begin in October 2012 a complex medical review of CPT code 99215, from which Connolly will be permitted to extrapolate their findings based on a statistical sample of such claims.

The AMA sent a letter to CMS Acting Administrator Marilyn Tavenner strongly objecting to these audits and urging CMS to rescind approval of RAC review of E&M codes.  Among the complaints voiced by the AMA were the following:

  • That “physician choices regarding appropriate code designation can be a subjective matter based on the complexity of the patient visit. Physicians who provide E&M care apply complex decision-making based on myriad clinical approaches… [and b]ecause of the complexity of this type of care, it does not lend itself easily to medical review.”
  • Because “the RACs are not required to have same-specialty physicians review RAC determinations, we have no confidence that the RACs will be up to the task of understanding these variables or their clinical relevance.”
  • “[T]he RACs have a low accuracy rate as it is: CMS’ FY2010 Recovery Auditor Report to Congress reported that 46 percent of the Medicare RAC determinations appealed were decided in the provider’s favor. RAC review of E&M codes will undoubtedly lead to erroneous recoupments and lengthy, expensive appeals for both physicians and CMS.
  • “Each E&M visit is different based on the unique needs of the patient. Assignment of levels of E&M services is based on six components…  Due to the variability and balance of these components from one visit to the next based on the needs of each patient, the use of the extrapolation method in an audit for comparison of visits among different patients has a high outcome probability of error and should not be used.”

Despite the AMA’s and state and specialty medical societies’ historic and unwavering opposition to the RAC audits of E&M services, there has been a recent increased pressure on CMS to review physicians’ coding of E&M services.  Specifically, the Health and Human Services Office of Inspector General issued a report in May on this topic that specifically urged CMS to encourage its contractors to conduct these reviews and “if CMS determines that inappropriate claims have been paid, it should take steps to recover those overpayments.”  

The take away for all providers – document, document, document….  Ensure that in the event that your E&M coding is questioned, your documentation will support your/your staff’s coding determinations. 

If you have any questions relating to this matter – or wish to discuss the elements that would qualify your office visit for a level 5 code, please do not hesitate to contact us at any time.


RAC Approved Issue #1 — Coding Services Supplemental To Principal Procedure Code (Add-On Codes)

In Uncategorized on May 10, 2011 at 9:15 pm

As discussed in the last post, this blog is going to dedicate some time to highlighting all of the approved issues for Region C’s Recovery Audit Contractor — Connolly.  Without further ado, the first item on Connolly’s list of “approved issues,” as identified by Connoly and CMS, which applies to physicians (as opposed to inpatient or outpatient facilities, ASCs, or DME suppliers) is:  the use of an add-on code without the primary code.  This audit issue is applicable to all of the states within Connolly’s Region C purview, and is applies to dates of service 10/1/2007  forward (however, it is important to note that the date of claim subject to a RAC audit cannot exceed three years from the current date — so, all the date of service must be no further back than May 8, 2008 for an audit sent today).

Pursuant to the CMS Manual, and the AMA’s CPT-Professional Edition, an add-on code designates a procedures which is commonly carried out in addition to the promary procedure performed (as distinguished from incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy), which are not separately billed).  These additional/supplemental codes enable physicians and others to separately identify a service that is performed in certain situations as an additional service, such as additional digit(s), lesion(s), neurorrhaphy(s), vertebreal segment(s), tendon(s), joint(s), or additional time.  These add-on codes are generally readily identified by terminology such as “each additional” or “list separately in addition to code for primary procedure,” or by a “+” symbol.  

Use of an add-on code is only appropriate when the same physician who provided the primary service also provided the additional add-on service.  Additionally, it is imperative that an add-on code never be reported as a stand-alone code — i.e., the add-on code must never be the only CPT code reported, rather, it must accompany the promary procedure code that it represents and enhances.  Finally, the add-on codes must never have the following modifiers appended to them:  -25, -51, or -59.  While all of these elements of the add-on codes are critical to compliant coding, it is the use od the add-on code as a stand alone code – without the primary CPT code – that will trigger a RAC investigation, for billing and subsequent payment of an add-on code without its respective primary code(s), results in unwarranted overpayments, repayment of which will be demanded by the RAC.


RAC Audits… Coming To A Practice Near You!

In Uncategorized on May 3, 2011 at 8:48 pm

When the Recovery Audit Contractors began their investigations into the possible overpayments (and underpayments – to a much, much lesser extent!) made by Medicare, they started with the deep pockets…  with the providers submitting the most claims…  with the hospitals.  In fact, it was widely expressed that it would take some time for the RACs to navigate their way through the morass of facility claims up for review before getting to the physician practices — especially solo practitioners.  Well, my friends, that time has come. 

While the RAC program has been in effect in some form, albeit initially provisional, since 2006, it went national in 2010.  And now physician providers are starting to see audit inquiries of their own.  This is no longer a facility investigation, nor an investigation into the coding and claim submissions of large practices.  It is a systemic audit of all claims — whether from a facility or a medical office, even down to the solo-practitioner.

Key to understanding the RAC process is the knowledge that the RACs are not only manually reviewing claims submissions, but are also utilizing computer algorithms which detect billing/coding abnormalities, prompting further investigation.  The computer will not discriminate based on the size of the provider, and will “review” claims of the 500-bed hospital in addition to the solo-practitioner serving a rural community.  Thus, the RAC impacts everyone, and it behooves everyone to understand and comply thoroughly with RAC audits!

Over the course of the next few months, M.E.D.I.C., Inc. will use this blog as a platform and take the opportunity to educate providers on the RACs – focusing specifically on the issues affecting our clients:  physicians (as opposed to facilities) and DME providers in Region C (the largest of the four RAC regions, covering 39% of the United States:  AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands), for which Connolly serves as the RAC.