CMS Shares Info on New Modifiers and RAC Improvements

on Monday, 02 March 2015. All News Items | Recovery Auditor | Coding

Trying to Communicate

Communication is key – we hear that all the time. And it is true and applies to all aspects of our lives, whether it is within our marriages and families, or in our work environments. But another truth about communication is that it is hard - hard to consistently communicate thoroughly and clearly, especially with written communication. We have probably all experienced difficulties with misinterpreted emails. Since most Medicare information is communicated in writing, I have to give CMS kudos for trying to communicate verbally via the open door forums, especially the call-in question sessions. These calls are generally informative but always entertaining.

On February 24, 2015 CMS held a Hospital Open Door Forum (HODF). In case you have never participated in one of these, representatives from CMS provide updates on current topics of interest to hospitals. This is followed by a question and answer session for listeners.  If you are interested in future calls, you can find information on the Hospital Open Door Forum website. The February HODF agenda included use of the new “X” modifiers and review of the Recovery Audit program improvements.

New “X” Modifiers

The main take-away from the new modifier discussion was to continue using modifier 59 for now. CMS has not published instructions for the use of the new “X” modifiers and is not yet requiring them for any code combinations.  Use of the new modifiers is allowed since they were effective January 1, 2015, but it is also acceptable at this time to continue to use modifier 59 following existing guidance for its usage. During the Q&A, providers asked about several scenarios for the use of the new modifiers – CMS responded that this was exactly why they should continue to use the 59 modifier – guidance addressing specific scenarios has not yet been published by CMS.

Some Medicare Administrative Contractors (MACs) have published guidelines and are presenting education offerings on the modifiers. But during the last Physician’s Open Door Forum call, providers reported this guidance was conflicting and confusing. CMS asked for examples of the confusing guidance and scenario questions from providers to help CMS as they develop their guidance on the use of the new modifiers.

Recovery Audit Program Improvements

CMS also reviewed the latest document on planned improvements for the Recovery Audit (RAC) program dated December 30, 2014. The twenty changes for improvements are listed below with notes regarding the HODF discussions.

*The first such note is that these improvements will be effective at the beginning of the next round of RACs. To date only one new RAC award is final due to numerous award protests. That means these improvements do NOT apply to current RAC activity.

  • Revisions to ADR limits
    • Limits adjusted due to provider’s denial rate (A1)
      * CMS has yet to determine how a provider’s denial rate will be calculated. It will likely be based mostly on the RAC denial rate, but other denials (such as MAC denials) may also be considered in the rate calculation. Appeal overturns may also factor into the denial rate calculation. The ADR limit adjustment will not be applied initially when the new contracts begin but will be adjusted as the denial rate is determined. CMS promised to share the initial baseline ADR volumes with provider associations prior to implementation of the new contracts to allow feedback.
    • Spread over all claim types for a provider (A3)
    • Incremental application for new providers (A4)
    • No increase for physicians with new contracts (A5)
    • Incremental adjustments for PIP hospitals (A11)
  • Adjustments to timeframes
    • Six-month look back for patient status reviews (A2)
    • Thirty (30) days for completion of complex reviews (A6)
      * A RAC’s failure to comply with this timeframe will be addressed in the RAC evaluation reviews and might impact the assignment of future contracts. It will likely not result in closure of specific reviews unless a pattern of non-compliance is noted.
    • Thirty days for discussion period before adjustment (A8)
  • Better communication with RACs and/or CMS
    • Confirmation of discussion request (A9)
    • More uniform provider portals (A10)
    • Increased public reporting of RAC data (B1)
    • Provider Relations Coordinator (C1)
    • CMS compliance tips (C2)
    • More detailed information on review issues (C3)
  • Increased standards and oversight for RACs
    • Medical Director required (A7)
    • No contingency fee until 2nd level of appeal exhausted (A12)
    • More diverse topics for review (B2)
    • Overturn rate of < 10% at first level of appeal required (B3)
      * Reversal during discussion period not considered in this overturn rate, but numerous reversals may be addressed by CMS outside of this process. Providers can report concerns about the volume of discussion period reversals to CMS.
    • Accuracy rate of at least 95% required (B4)
    • Possible provider satisfaction survey (C4)

As you can see, some good information from this Hospital Open Door Forum. Again, kudos to CMS for successful communication.

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..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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