ED NOTE: RAC Monitor published a brief article after a CMS Outreach Session on the RAC program in which questions were taken from attendees and answered by CMS. The session, conducted last June, created some general concern and confusion, and RAC Monitor later was invited to interview CMS officials to discuss concerns related to "reach-through takebacks" for Part A and Part B providers. This article is the second of two providing the questions and answers from that interview.

Commander Marie Casey, deputy director of CMS's Audit Division, spoke frankly and directly with RAC about concerns that had been expressed by many providers after reports were published regarding remarks made at provider outreach sessions concerning when, what or even if physician providers were going to be audited by RACs during the permanent program.

Present on the CMS call were: Connie Leonard, director of the CMS Division of Recovery Audit Operations; Commander Marie Casey, deputy director of the division; Howard Coan of the CMS Press Office; Chuck Buck, President/CEO of RAC Monitor; Patricia Dear, RAC Monitor Editorial Advisory Board and president/CEO of eduTrax; and Ernie de los Santos, RAC Monitor Contributing Editor and vice president of technology for eduTrax.

National Provider Identifier (NPI) Background

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.

As outlined in federal regulation contained in, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

RAC Medical Record Requests and NPI Numbers

As a part of the interview with Casey the following question was asked and answered:

Question: The number of medical records which can be requested by RACs is up to a maximum of 200 per NPI for inpatient, and for outpatient services also a maximum of up to 200 records per NPI every 45 days. What if the provider has one NPI for both inpatient and outpatient services - would that be 200 for inpatient & outpatient combined, for a maximum total of 200, or 200 for inpatient plus 200 for outpatient for a total of 400 under the one NPI?

Answer:  As of now and "on the record," it is a maximum 200 records per NPI. However, where a hospital provider may have more than one NPI, but have only one (shared) medical records department for the organization (or campus), the maximum would still be 200 every 45 days.

Follow-up Question: So where a hospital provider provides multiple outpatient services, inpatient services, has an acute inpatient rehabilitation program (IRF), each with different NPI numbers, would the total be 200 per service category or 200 for the total hospital?

Answer: No, it would be 200 for the total.

Follow-up Question: Where is this information posted?

Answer: We are purposefully holding off posting that information until the fall, as we are trying to focus on getting the RACs up to speed with the process and the beginning of the "automated" recoupments, adjustments that will start this month (August).

As I stated in Part I of the interview posted last month, the conversation with Casey was insightful and open, and it brought clarity to previously misunderstood information. That said, however, while monitoring the CMS RAC question and answer, which can be found on the CMS Web site, a few interesting and relevant questions were posted and answered as reproduced below. However, no specific information has been posted as of the date of this article regarding NPI and record maximum limits - stay tuned on that issue.

On Sept. 25, 2009, a question and answer (Q&A) was posted on the CMS RAC Web site regarding medical record request limits, which follows in its entirety:

"Question: I heard that RAC medical record request limits will be based on my 2007 claims volume, then I heard on 2008. Which is it?

Answer: We apologize for the confusion. Limits in the remainder of the fiscal year ending September 30, 2009, are based on claim volume in the 2008 calendar year. This differs from our original announcement that limits in the current year would be based on 2007 claim volumes.

Our original plan was to use the previous calendar year's volume to calculate the following fiscal year's limits. In other words, we envisioned using claims paid from January 2007 through December 2007 to develop limits for October 2008 through September 2009. Claims paid in calendar 2008 would then drive limits in fiscal 2009, calendar 2009 would drive fiscal 2010, and so on.

Unfortunately, the RAC program was subject to a several month delay while various contract issues were being resolved. By the time we were ready to resume work in February 2009, claim data for all of 2008 was available. Recognizing that many providers have grown or contracted due to changes in the economic environment, we decided to use the most current figures available to us instead.

We recognize that the calendar/fiscal year schedule is confusing and were exploring other alternatives for future years. We welcome suggestions at rac@cms.hhs.gov."