Are Recovery Auditors Reviewing Your Claims?
Recovery Auditors have been busy. This year alone there are 23 topics under review and three more were just proposed. If you are coding/billing for any of the topics under review, this may be all the reason you need to conduct an internal review.
Who Are They?
Recovery Auditors, or Recover Audit Contractors (RACs), review claims on a post-payment basis for the purposes of detecting and correcting past improper payments. The Centers for Medicare & Medicaid Services (CMS) and contracted payers then implement actions that will prevent future improper payments.
Current RACs are:
Region 1 – Performant Recovery, Inc. (CT, IN, KY, MA, ME, MI, NH, NY, OH, RI, VT)
Region 2 – Cotiviti, LLC (AR, CO, IA, IL, KS, LA, MO, MN, MS, NE, NM, OK, TX, WI)
Region 3 – Cotiviti, LLC (AL, FL, GA, NC, SC, TN, VA, WB, Puerto Rico, US Virgin Islands)
Region 4 – HMS Federal Solutions (AK, AZ, CA, DC, DE, HI, ID, MD, MT, ND, NJ, NV, OR, PA, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas)
Region 5 – DME/HHH/Performant Recovery, Inc. (Nationwide)
Region 1-4 RACs perform post-payment reviews on Medicare Parts A/B claims and the Region 5 RAC reviews Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and home health/hospice (HHH) claims.
Current Topics Under Review
Table A lists all the topics for review beginning in 2019. Details of these reviews are available on the CMS’ Medicare Fee for Service Recovery Audit Program website. The details provide clues for what to look for.
For example, details for HCPCS A4253: Blood Glucose Test or Regent Strips tells us that Recovery Auditors initiated complex reviews of claims submitted by DME suppliers and providers in all states beginning March 5. Documentation will be reviewed to determine if the utilization guidelines for blood glucose test strips (A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips) were met. Here’s the clue: “The quantity of glucose test strips that are covered depends on the usual medical needs of the diabetic patient.” Meaning, they’re looking at documentation to support the units billed.
A list of references to applicable policies is also given (although, unfortunately, not hyperlinked). Best practice is to go to the payer’s website and look up their policy for A4253.
For example, Noridian Medicare’s Local Coverage Determination L33882 tells us that the quantity of test strips covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having type 1 or type 2 diabetes mellitus. The LCD includes complete coverage guidelines of these testing supplies.
Table A: Approved RAC reviews initiated in 2019
|Name||Review Type||Claim Type||Region|
|Medical Necessity Pannulectomy||Complex||Outpatient Hospital, ASC, Professional||A/B MACs|
|Pneumatic Compression Device||Complex||DME Suppliers/Providers||DME MACs A-D|
|E/M Save Day as Admission to a Nursing Facility||Automated||Physician/NPP||A/B MACs|
|PET Scans Paid without Tracer Codes||Automated||Independent Diagnostic Testing Facility||A/B MACs|
|Cryosurgery of the Prostate||Complex||Outpatient Hospital, ASC, Professional||A/B MACs|
|Cardiac Rehabilitation||Complex||Outpatient Hospital||A/B MACs|
|Complex Chest X-ray||Complex||Outpatient Hospital, Professional||JE, JF|
|IV Hydration Administration||Complex||Outpatient Hospital||JE|
|SNF-Consolidated Billing for Therapies||Automated||Physician/NPP, PT, OT, SLP||All States|
|Complex Medical Necessity Vertebroplasty and Kyphoplasty||Complex||Outpatient Hospital, ASC, Professional||A/B MACs|
|Pulmonary Rehab||Complex||Outpatient Hospital||All States|
|Therapeutic Shoes and Inserts for Persons with Diabetes||Complex||ASC, SNF||DME MACs A-D|
|ASC Services During a Covered Part a SNF Stay||Automated||ASC, SNF||All States|
|Medical Necessity for Vitamin Assay D Testing||Complex||Laboratory Service||JE/JF|
|Off-the-shelf Knee Orthosis||Complex||DME Supplier/Provider||All DME MACs|
|Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins||Complex||ASC, Outpatient Hospital, Professional||A/B MACs|
|Unbundling of CT Scans||Automated||Outpatient, Professional||All States|
|Unbundling of MRI Procedures||Automated||Outpatient, Professional||All States|
|Knee Orthosis within the RUL||Automated||DME Supplier/Provider||All DME MACs|
|Subsequent Hospital Visit and Discharge Day Management Billed on Same Day||Automated||Professional||All Regions|
|Mohs Micrographic Surgery: Units Billed||Complex||Professional||All Regions|
|Physician/NPP Coding Validation||Complex||Professional||All Regions|
|HCPCS A4253: Blood Glucose Test or Reagent Strips||Complex||DME Supplier/Provider||All DME MACs|
Proposed Topics for Review
Recovery Auditors also propose to conduct complex reviews for the topics shown in Table B.
Table B: Proposed topics for review
|Name||Review Type||Claim Type||Region|
|ASC Coding Validation||Complex||ASC||All Regions|
|Medical Necessity for ALS and BLS Non-emergency Ambulance Services||Complex||Laboratory, Ambulance||All Regions|
|Upper Limb Orthosis within the RUL||Automated||DME Supplier/Provider||All DME MACs|
Take a proactive approach: Audit claims for improper payments and correct coding and documentation discrepancies for optimal revenue cycle management.
CMS, Medicare Fee for Service Recovery Audit Program