January 23, 2020

Are You Prepared for RAC Audits in 2020?

The Centers for Medicare and Medicaid Services (CMS) recently released the new list of proposed and approved Recovery Audit Contractors (RAC) audit topics.

It is important to stay in the know on proposed and approved topics that RACs are able to review. These topics are updated quarterly on the RAC review topic webpage. Physicians and group practices should monitor these topics to prepare for potential audits. It is likely that proposed RAC topics will be approved within a month of initial proposal, though approvals can take somewhat longer based on CMS internal review processes.

Background

The Medicare Fee for Service (FFS) Recovery Audit Program’s identifies and corrects improper Medicare payments through the efficient detection and collection of overpayments for claims of health care services provided to Medicare beneficiaries and the identification of underpayments to providers, so CMS can implement actions that will prevent improper payments in the future.

Four recovery audit contractors have been assigned to review and audit select claims. A statement of work outlines tasks and responsibilities associated with the review of Medicare FFS claims submitted to the A/B Medicare Administrative Contractors (MACs) in Recovery Audit Regions 1 through 4. RACs shall maintain a quality customer service center to provide accurate and timely responses to CMS and provider inquiries and outreach.

Two proposed RAC topics will affect imaging services:

1. Procedures that Include Ultrasound: Incorrect Coding

 The focus of this issue is to target claims where there was an additional payment made for imaging due to incorrect coding. If the provider billed a procedure code where the definition of the code does not include ultrasound and then billed ultrasound, the service will be re-coded to the code that includes ultrasound and the ultrasound will then be denied.

Affected Code(s): 10021, 20605, 20610, 32554, 32556, 49082, 76942, 76998


2. Procedures that Include Imaging: Unbundling

The focus of this issue is to target claims where the definition of the procedure code includes imaging and imaging was then unbundled. This audit review will affect all modalities within the radiology section of the AMA CPT manual. CMS has provided no further information at this time.

Affected Code(s): 70010-79999

Preparing for RAC Audits

 The proposed topics listed above have been selected as an automated review. No medical records are requested or reviewed. Discovery is done through data mining. All automated reviews initiated after Jan. 1, 2016, will be posted on the RAC Provider Portal when they are identified. This will serve as the start of the provider’s 30-day window for a discussion request. Providers should monitor their RAC websites for updates on approved new issues. This will assist providers in better understanding what audits are taking place so they can prepare to respond to RAC requests. Here are two resources provided by Cotiviti LLC for Region 2 and 3:

KEEP IN MIND — The role of the RAC is to select the claims and to conduct the review. The role of the MAC is to process any resulting adjustments and to serve as the conduit for any subsequent appeal activity. Therefore, you should contact your designated RAC to answer questions pertaining to anything in the RAC process up to the point when the claim may be pending adjustment with the MAC.

Questions or concerns about the Recovery Audit Program should be directed to CMS via email at RAC@cms.hhs.gov.