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RAC Court Ruling Deals Blow to CMS

A US Court of Appeals ruling earlier this month that invalidates a provision of Medicare’s 2014 Recovery Audit Program contracts is the latest setback for federal officials who administer the program. Best Medical Coding Course!

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2015 U.S. Department of Health and Human Services Office of Inspector General Work Plan is Published

As you may be aware, the 2015 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan was released on Oct. 31, 2014. This should be considered mandatory reading for all healthcare providers looking to avoid fraud charges.

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Auditing Modifiers

It is not enough to merely audit the codes billed by the provider of healthcare services.

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RAC audits: Can an EHR system help you avoid a visit?

We’ve all probably heard about how an electronic health record (EHR) system can streamline your practice. What about audits? Can EHRs really help you mitigate risk from recovery audit contractors (RACs)?

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Just the RAC Facts: Controversial Program Roots Out Fraud, Waste in Medicare

Here are the facts: Medicare is one of the largest insurance programs in the United States, and every year it helps insure more than 49 million seniors and other beneficiaries. And, for a variety of reasons, its prognosis is anything but certain; estimates indicate that Medicare will be bankrupt by 2026.

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OIG Seeks Improvements To RAC Program, Enhanced CMS Efforts To Stop Improper Medicare Payments

The OIG has called on CMS to strengthen activities to prevent improper Medicare payments, including enhancements to the Recovery Audit Contractor (RAC) program.

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AHA Survey: Medicare RAC Audits Up 47% Since Last Year

The number of Recovery Audit Contraction (RAC) requests for medical claims reviews has increased “dramatically” since 2012, according to the American Hospital Association’s (AHA) newest RACTrac survey.

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Medical Coding Audits – Absolutely Vital for Every Medical Practice

Physicians are very often so stressed out with seeing an increasing number of patients, providing medical services and appropriate follow-ups that they hardly get any time to see to the coding and billing processes themselves.

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CMS Adjusts Medicare RAC Documentation Limits

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History of Present Illness Must Be Taken by MD, NPP

Don’t let nurses do the doctor’s work, or risk downcoded E/Ms upon audit.

The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to a June 4, 2010 Frequently Asked Questions (FAQ) answer from Palmetto GBA, Part B carrier for Ohio. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it.

Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI),  Palmetto says.

Exception: In some cases, an office or Emergency Department triage nurse can document “pertinent information” regarding the Chief Complaint or HPI, Palmetto says. But you should treat those notes as “preliminary information.” The doctor providing the E/M service must “document that he or she explored the HPI in more detail,” Palmetto explains.

Other payers have expanded on Palmetto’s announcement, letting physicians know that they cannot simply initial the nurse’s documentation. For example, Noridian Medicare publishes a policy that states, “Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be ‘I have reviewed the HPI and agree with above.’”

Good news: Thanks to this clarification, your doctor won’t have to repeat the triage nurse’s work. Right now, if the nurse writes “knee pain x 4 days,” at the top of the note, some auditors might insist that your doctor needs to write “knee pain x 4 days” in his/her own handwriting underneath. But that requirement is a thing of the past if your carrier echoes Palmetto’s requirement.

Bad news: Now this carrier has made it…

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Recovery Audit Contractors: Know These RAC Fast Facts

RACs are just another tool in the government’s arsenal to collect improper payments.

You’ve got so many compliance acronyms flying at you every day that you may not be able to differentiate your RAC from the OIG. Know these quick facts about RACs to stay better informed.

  • Recovery audit contractors (RACs) detect and correct past improper payments so CMS and the MACs can prevent such problems in the future
  • RACs are hired as contractors by the government, and they can can collect “contingency fees,” which means that they get a percentage of the amount that they recover from providers who were paid inappropriately The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007
  • Between 2005 and 2008, RACs involved in the original demonstration project recovered over $1.03 billion in Medicare improper payments, but referred only two cases of potential fraud to CMS, according to a February OIG report on the topic, which noted that “because RACs do not receive their contingency fees for cases they refer that are determined to be fraud, there may be a disincentive for RACs to refer potential cases of fraud.”
  • Unlike RACs, the OIG is a government entity. Although the OIG also performs reviews and audits and seeks improper payments, the OIG does not collect contingency fees.

For more on the RAC program, visit

Part B Insider. Editor: Torrey Kim, CPC

Sign up for the upcoming live Webinar, You Can Use the Appeals Process Like a Pro, or order the CD/transcripts.

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Auditors Review Your Notes Based on the Regs as of the Service Date

auditorIf you performed a consult in 2006, the auditor will use 2006 guidelines — not today’s rules.

Most Part B practices have grown accustomed to tucking consult regulations into the backs of their minds, since Medicare no longer pays for…

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EM CODING: Don’t Bill High-Level E&M Codes Until You Read This

Sicker patients may not always mean higher MDM.

If your physician bills a lot of high-level office visits, he may be at risk of an audit — which may not be cause for concern — if his documentation justifies his…

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Gastro Coders: Be Aware of Medicare Screening Reqs Or Risk Payment Denial

Following 10-year-rule eliminates G0121 rejection.

If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.

Use this guidance to capture every screening dollar your gastroenterologist deserves.

Home in on Eligibility Requirements for

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Audits: HDI RAC Targets TC, Modifier 26 & More

Want to know what RAC contractors will be looking for next? Here’s the link.
Recovery audit contractors (RACs) are working hard to expand their lists of approved issues, and you should keep a close eye on your services in these areas as well.
Health Data Insights (HDI), the RAC contractor for Region D, posted 66 new approved […]

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  1. CMS COVERAGE DECISIONS: MACs Can Make Exceptions to LCDsRACs can make exceptions only to approve claims. Coders know local coverage…
  2. RAC Fact Did you know that those new RAC auditors out…
  3. RAC Fact: Watch Out For Medicare’s Once-in-a-Lifetime Services G0389 & the IPPE codes may be potential RAC…
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Global Billing: Document ‘Unrelated’ for Modifier 79 Services

MACs are looking for ‘red flags’ to halt additional global period pay
Billing for additional services during a global surgery period is always tricky, but now you can expect special scrutiny for modifier 79 claims.
After the OIG got wind of fraudulent surgery billing with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), CMS contractors have been on the hunt […]

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  1. These 8 Services Are Not Part Of The Global Surgical PackageIf you’re not reporting these services separately, you’re losing money….
  2. Modifier Cheat Sheet: Banish Your E/M Modifier Phobias ForeverOnce you have this tool, you’ll never again wonder which…
  3. Bone Up On ASC Orthopedic Coding With These Global Period, Modifier Tips 3 ways your physician claim better look different than…
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