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Proposed Recovery Auditor Contractor (RAC) Reviews

Nov 30, 2017

On November 13, 2017, the Centers for Medicare and Medicaid Services (CMS) began posting to their website a list of topics that have been proposed, but not yet approved for Recovery Auditor Contractor (RAC) Review. The information will be updated monthly and can be accessed on their “Provider Resources” webpage at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Provider-Resources.html

The original listing of proposed topics for RAC review includes:    

  • Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary    
  • Respiratory Assistive Devices: Meeting Requirements to be considered Reasonable and Necessary
  •  Excessive or Insufficient Drugs and Biologicals Units Billed
  •  E&M Codes billed within a Procedure Code with a “0” Day Global Period (Endoscopies or some minor surgical procedures)  
  • E&M Codes billed within a Procedure Code with a “10” Day Global Period (other minor procedures)
  • E&M Codes billed within a Procedure Code with a “90” Day Global Period (major surgeries)

These proposed topics, if approved, can be reviewed by RACs in any state. Although only the last three items will be billed as “Part B Professional Services”, coverage review of any of the above listed items will be based, at least in part, on physician documentation. The affected codes can be found on the above-referenced website, except for the first item, which is not code-dependent.