By: Cheryl Servais, MPH, RHIA

Although CMS has published this phased-in review schedule, it seems likely that the timing once again will slip. A review of all four RAC Web sites today did not reveal any targets for conducting audits or reviews. In fact, the site for Health Data Insights (Region D) is still under construction.

CMS RAC Review Phase-in Strategy

(as of 6/24/09)

CMS states on its RAC home page "Any reviews completed by the RAC must have been first approved by CMS and posted to the RAC websites. The RAC websites can be found in the RAC contact information document in the downloads section below. CMS expects the first approved new issues to be posted in July 2009."

What is the process for automated reviews?

According to CMS, automated review occurs when a RAC makes a claim determination at the system level without a human review of the medical record.

The RAC may use automated review when making coverage and coding determinations only when BOTH of the following conditions apply:

1. There is certainty that the service is not covered or is incorrectly coded, AND

2. A written Medicare policy, Medicare article or Medicare-sanctioned coding guideline (e.g., CPT statement, CPT Assistant statement, Coding Clinic statement, etc.) exists.

When making coverage and coding determinations, if no certainty exists as to whether the service is covered or correctly coded, the RAC shall not use automated review. When making coverage and coding determinations, if no written Medicare policy, Medicare article, or Medicare-sanctioned coding guideline exists, the RAC shall not use automated review. Examples of Medicare-sanctioned coding guidelines include CPT statements, CPT Assistant statements, and Coding Clinic statements.

The RAC may use automated review when making other determinations (e.g. duplicate claims, pricing mistakes) when there is certainty that an overpayment or underpayment exists. Written policies/articles/guidelines often don't exist for these situations.

What types of edits will the RAC use to make these "automatic"  determinations about the appropriateness of reimbursement?

National Correct Coding Initiative (NCCI) edits - These are combinations of Current Procedural Terminology (CPT) codes that cannot be used together due to rules defined by the AMA in the CPT Coding Manual. If one of the prohibited combinations appears within a claim, it would be an automatic reason to deny reimbursement associated with the second code of the pair, unless an appropriate modifier was appended to that code. The CCI Edits Manual can be purchased from the National Technical Information Service (NTIS) Web site at www.ntis.gov/products/cci.aspx.

Medically Unlikely Edits (MUEs) - these edits look for units of service that are in excess of what would be the maximum expected for a particular CPT code for a beneficiary on the same day of service. To establish MUEs, CMS created unit restrictions based on anatomy, CPT code descriptions, CPT Manual instructions, CMS frequency/billing policies, nature of service/procedure and clinical judgment.

These edits do not preclude any reviews for medical necessity of any service or procedure for which a provider submits a claim. MUEs were implemented on Jan. 1, 2007 and continue to be updated quarterly. Not all MUEs are posted, but the ones that are available may be found at www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage