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CMS approves Medicare RAC to review E&M claims

November 6, 2012

For the first time, a Medicare Recovery Audit Contractor (RAC) has been approved by the Centers for Medicare & Medicaid Services (CMS) to review evaluation and management (E&M) services.

Specifically, Connolly, the RAC in Region C, may now review claims paid in the last four years for Current Procedural Terminology (CPT) code 99215 in:

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico and the U.S. Virgin Islands.

Although most optometrists and other physicians do not frequently bill this code, a report by the Office of the Inspector General (OIG) of the U.S. Department of Health & Human Services (HHS) earlier this year found that 2.2 percent of physicians who consistently bill higher level E&M codes were optometrists.

A full report from AOA on this HHS-OIG report can be found at http://newsfromaoa.org/2012/09/12/hhs-oig-medicare-em-costs-increasing.

The OIG did not assess the accuracy of the coding, but the RAC will now attempt to determine whether the service was billed correctly.

The AOA suggests that members be sure to read and respond to communication from Connolly, and to be prepared to appeal negative RAC determinations.

More information from the CMS on this topic is available at http://www. cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/index.html.

AOA members with questions or concerns should contact the AOA Washington office team at 800-365-2219 or ImpactWashingtonDC@aoa.org.

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