Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 04, 2012 PDF

Connolly becomes the first RAC to focus on E/M inaccuracies.

Recovery audit contractors (RACs) have reviewed scores of issues over the past several years, but perhaps none has been as all-encompassing as the latest decision. RAC contractor Connolly announced on Sept. 12 that it would begin to review E/M claims to find those that were paid incorrectly in 15 states as well as Puerto Rico and the Virgin Islands.

Connolly's announcement raised the ire of physicians across the country. The decision will impact nearly every practice in Connolly's region that performs face-to-face services, and will span dates of service from Oct. 1, 2007 and onward.

The RAC will be focusing intently on high-level established patient office visit code 99215, CMS said in a letter to the AMA. "CMS appears to have also granted Connolly authority to extrapolate its review of sample claims to potentially recoup funds on 99215 claims it did not evaluate individually," the AMA said in a Sept. 26 news wire.

Most physician organizations cringed at the thought of a RAC not only scrutinizing 99215 but also projecting its statistical findings to services that the RAC didn't review. The AMA wrote a strongly-worded letter to CMS Administrator Marilyn Tavenner expressing displeasure.

"RAC review of E/M codes will undoubtedly lead to erroneous recoupments and lengthy, expensive appeals for both physicians and CMS," said AMA CEO James L. Madara, MD in the Sept. 11 letter. "We strongly urge CMS to reevaluate their approval of RAC review of CPT® code 99215 in light of CMS' other robust efforts to encourage comprehensive, complex care, as the approval of this RAC review is incongruous with CMS' stated priority to strengthen and support high-quality, patient-centered care."

Likewise, Susan Turney, MD, president of the Medical Group Management Association (MGMA), wrote a letter on Sept. 25, also urging CMS to reconsider its decision.

Despite the opposition, however, the issue is still listed on Connolly's Web site (http://www.connolly.com/healthcare/pages/ApprovedIssues.aspx), indicating that these audits may have already begun.

The affected states are Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, and West Virginia.