10 Service/Supply Claims Under Review

If your provider furnishes Medicare patients with any of the services or supplies on this list, expect an ADR.

Ever wish you had a crystal ball to foresee when a Recovery Audit Contractor (RAC) might send your office an Additional Documentation Request (ADR) letter? Luckily, all you really need is the World Wide Web; RACs post the issues they are reviewing on their websites. If your provider bills for any of the procedures or durable medical equipment (DME) on their radar, it may be a good time to conduct an internal audit on those claims. Here are the 10 most recent issues the Centers for Medicare & Medicaid Services (CMS) has approved for RAC complex review.

What Is a RAC?

CMS created the Medicare Fee-for-Service (FFS) Recovery Audit Program to identify and correct improper payments. RACs are third-party companies that review claims on a post-payment basis to detect and correct past improper Medicare payments.

RACs in Regions 1-4 perform post-payment reviews to identify and correct Medicare Parts A and B claims. The Region 5 RAC is dedicated to national review of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and home health agencies (HHAs)/hospice claims.

To date, the RACs are:

  • Performant Recovery, Inc.
    • Region 1 (Conn., Ind., Ky., Mass., Maine, Mich., N.H., N.Y., Ohio, R.I., and Vt.) (Performant was awarded region 1 on March 26)
    • Region 5 (Nationwide for DMEPOS/HHA/hospice)
  • Cotiviti
    • Region 2 (Ariz., Colo., Ind., Ill., Kan., La., Mo., Minn., Miss., Neb., N.M., Okla., Texas, and Wis.)
    • Region 3 (Ala., Fla., Ga., N.C., S.C., Tenn., Va., W.Va., Puerto Rico, and U.S. Virgin Islands)
  • HMS Federal Solutions
    • Region 4 (Alaska, Ariz., Calif., D.C., Del., Hawaii, Idaho, Md., Mont., N.D., N.J., Nev., Ore., Pa., S.D., Utah, Wash., Wyo., Guam, American Samoa, and Northern Marianas)

RAC reviews usually result from referrals made by Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and federal investigative agencies such as the Office of Inspector General (OIG) and the Department of Justice (DOJ).

Top 10 List

The following top 10 approved issues are for complex review of medical necessity and documentation requirements:

  1. Spinal cord neurostimulation (CPT® 63685, 63650, 63655) for outpatient, inpatient, ambulatory surgical center (ASC), and professional services claims
  2. Positron emission tomography for initial treatment strategy in oncologic conditions (CPT® 78608, 78811-78816, A9552) for outpatient and professional services claims
  3. Next generation sequencing (CPT® 81455, 0111U, 0022U, 0037U) for laboratories
  4. Hospice continuous home care (revenue codes 0652 Continuous home care, 0551 Skilled nursing visit, 0571 Home health aide visit, and HCPCS Level II codes G0299, G0300, G0156)
  5. Vagus nerve stimulation (CPT® 64568, 64569, 61885) for outpatient, ASC, and professional services claims
  6. Air ambulance for rotary wing (helicopter) aircraft claims (HCPCS Level II A0431, A0436)
  7. Deep brain stimulation (CPT® 61885, 61886, 95970, 95972, 95973) for outpatient claims
  8. Immunosuppressive drugs (HCPCS level II J7507) for DME claims
  9. Implantable automatic defibrillator (ICD-10-PCS 0JH608Z, 0JH609Z, 0JH638Z, 0JH639Z, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z) for inpatient claims
  10. Polysomnography (CPT® 95810, 95811) for outpatient claims

If you go to the CMS website, you can review all approved RAC topics. Each approved RAC topic includes a description, affected codes, and applicable policy references. The applicable policy references section is very helpful as it lists all the regulatory guidelines RACs will use to perform their reviews.

For example, for Next Generation Sequencing reviews, RACs will consider 17 applicable resources including the Social Security Act, Title 42 Code of Federal Regulations, the Medicare Benefit Policy Manual, the Medicare Program Integrity Manual, the Medicare National Coverage Determination Manual, and the CPT® and ICD-10-CM code books.

Use these same references in your internal audits to ensure your claims are coded correctly and that you have documentation to back up those claims.



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