A Boom in RAC Activity

on Tuesday, 22 January 2013. All News Items | Recovery Auditor

According to reports from our clients, there has been a recent boom in the activity of Recovery Auditors (RAs or formerly and still commonly known as RACs). We are guessing this increased activity may be due to the resolution of differences in the application of Medicare rules between the RACs and Medicare Administrative Contractors (MACs). A recent change in the RAC process requires the approval of audit issues by the MACs. This is evidenced by the application of new RAC audit issues to specific MAC jurisdictions.

Some of the issues being hit hard according to client reports and our recommendations on addressing these proactively are:

  • The automated review of NCCI edit pairs,
    • Make sure you have updated edits in your claims system to alert you to all NCCI code pairs. Evaluate the code pairs carefully and remove codes that were inappropriately reported (unbundled) or when appropriate bypass the NCCI edit by appending a modifier. Be cautious not to bypass NCCI edits with modifiers when the services are not separate and distinct.
  • Excessive units of injection/infusion initial administration codes,
    • Only one initial drug administration code is allowed per access site per encounter by Medicare. Review charging or coding instructions with those in your facility that enter drug administration services. If multiple access sites are used or if a patient has multiple encounters in one day, it is appropriate to report more than one initial drug administration service; append modifier -59 to the second initial service in these circumstances.
  • Complex review of the medical necessity of lower extremity joint replacement, DRG 470.
    • Make sure your documentation includes what is necessary to support the medical necessity of these joint replacements. This may require physician education or obtaining copies of physician’s office notes of the patient’s history to include in the hospital’s medical record. See the October 2012 article on “Major Joint Replacement Documentation Revisited” on our website for more information.

**MMP, Inc. would love to hear your RAC experiences, so drop us a note and let us know if you have seen an increase in requests or denials and what issues are being targeted.

Connolly, the Recovery Auditor for Region C, recently published several new outpatient issues. These include:

  • Medical necessity of cardiac rehab and intensive cardiac rehab. This is an automated review that evaluates the diagnoses submitted on the claim.
  • An automated review of packaged observation services.
  • A semi-automated review of modifier 74 appearing on claims when there is no record of anesthesia. Semi-automated reviews consist of two parts - first the RAC selects claims as in an automated review for a potential improper payment. A notification letter is then sent to the provider who has 45 days to send documentation that supports the billing to the RAC. If the RAC does not receive documentation that supports the services billed, payment will be recouped. Note that modifier 74 is for services that are reduced, cancelled or discontinued after the administration of anesthesia.
  • Denosumab (J0897 or C9272) administration that exceeds the FDA-approved frequency of 60 mg every 6 months for Prolia® and 120 mg every 4 weeks for Xgeva®. This is a complex review and drug administration services may also be recovered.

All of Connolly’s issues can be viewed on their website or check out the lists of Connolly issues (most recent issues highlighted) on the Resource page of the MMP, Inc. website.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it. .


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