CODING & REIMBURSEMENT

When a RAC audit happens to you

By Suzanne Corcoran

RAC audits have been occurring more frequently lately. Here are some hints to help if you get the letter.

Q What are the Recovery Audit Contractors (RACs) auditing?

A Many important issues are targeted by the RACs. Of particular interest to ophthalmology are new patient codes and blepharoplasty procedures.

New patient codes

A new patient is defined as one who has never received services from any physician within the group of the same specialty, or has not been seen in more than three years. In the past, this definition was applied to the group so that if a physician changed practices and patients followed him to the new group, the new group could bill the patient as being new.

Now, Medicare deems that a professional relationship exists based on the individual doctor’s national provider identifier (NPI) as well as the group NPI. This change has resulted in RAC audits requesting refunds for patient exams billed as new when either the physician or the group has seen the patient within three years. These are automated audits; CMS does not request medical records before it issues a demand letter.

In most cases, these claims are being changed from new patient codes to the equivalent established patient codes, and CMS issues a refund demand for the difference. However, in some cases, we’ve seen CMS simply deny the new patient code and demand a refund for the full amount. When this happens, you may submit a redetermination showing why Medicare should allow an established patient visit. Be sure to review the record carefully to document the level of established patient visit.

Blepharoplasty

Both surgeons and facilities (hospital outpatient departments and ASCs) are receiving requests for medical records supporting the medical necessity of lid procedures. Responding to these audits is fairly straightforward, but keep in mind that your local policy (LCD) makes the rules for documentation and requirements for reimbursement. Check frequently as they do change over time.

Be sure your documentation clearly indicates a functional complaint. Watch out for words that would indicate a cosmetic reason for the surgery. The operative report must clearly describe the procedure(s) performed and, again, should show functional impairment being corrected. Send the visual field test and external photos. We have seen many instances where color photos were submitted, but the contractor scanned or copied the photos before sending them to the reviewer. This has resulted in denials stating that photos were not sent or did not support the procedure. If you get this denial, follow up diligently with the contractor. Do not let this get away.