Medicare Recovery Audit Contractor (RAC) to begin auditing E & M services

Saturday, October 20, 2012 12:43 PM
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The Centers for Medicare & Medicaid Services (CMS) has alerted the AMA that it has approved the Medicare Region C Recovery Auditor (RAC) Connolly to begin conducting audits of coding for E&M services in physician offices, specifically CPT code 99215.  We have been informed that in the next several weeks, Connolly will begin complex medical review of CPT code 99215, and will be permitted to extrapolate their findings based on a statistical sample of such claims.  Connolly is the Medicare FFS RAC contractor who conducts RAC audits in AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico and the U.S. Virgin Islands.  However, it has not yet been announced if all or only a subset of these states will be under review.  These reviews are expected to begin imminently in Region C and, according to CMS, are likely to be approved in other Medicare regions in the near future.

The AMA has 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.  We also have alerted CMS staff that there will be significant opposition and questions about these audits among medicine and have requested that they provide briefings for state medical societies and specialty societies in the next few weeks to hear these concerns directly.  We have yet to confirm these briefings but will inform you of their status once confirmed.  Recently, however, there has been increased pressure on CMS to review physicians’ coding of E&M services.  The HHS Office of Inspector General (OIG) issued a report here 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 AMA will continue to keep the Federation informed of this development and of our advocacy on this front, and in turn we will alert you. 

Physicians and their staff can find more information and resources on audits on the AMA’s Practice Management Center website here. In addition there is a recording of an earlier webinar on Medicare and Medicaid audits called “What physicians need to know” available here.

Posted in: Colorado Medicine | Cover Story | ASAP


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