Updated on: January 30, 2013

Medicare Ups RAC Documentation Request Limit for Some Providers

Original story posted on: August 21, 2011










Recovery auditors will be able to ask for up to 35 records every 45 days from providers that bill fewer than 27,200 claims, according to a RAC update from CMS.

The change, effective Aug. 22, is an increase for those providers that now are limited to 34 additional documentation requests or fewer because of the relatively small number of claims they bill.

The maximum number of requests - 300 every 45 days - remains unchanged since its implementation Nov. 2, 2010.

For more information on the change, log onto www.cms.gov/rac or http://www.aha.org/aha/content/2011/pdf/11racadrlimits.pdf.


New RAC Issues Posted

RAC regions B and D posted new issues this week. CGI Federal, the RAC for Region B, posted one issue related to durable medical equipment claims. HealthDataInsights, the RAC for Region D, posted two issues related to Part B claims.

Durable medical equipment (DME)

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Multiple DME rentals billed per month


RAC Region B

Medicare makes payments on a monthly basis for the rental of DMEPOS Fee Schedule items. The first claim's billing date for the DMEPOS rental item is designated as the anniversary date. All subsequent billing must be dated monthly with the anniversary date. If a claim is submitted with a date that is earlier than the anniversary date and that DMEPOS item is not a replacement for a lost, stolen or irreparable damaged DMEPOS item, then the claim represents an overpayment.

Social Security Act, Volume 1, Title XVIII; Federal regulations: Title 42 CFR Public Health; CMS IOM 100-04; Jurisdiction B DME MAC Supplier Manual Chapter 15


Part B

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Facet joints denervation billed without guidance J1-by ASC


Calif., Hawaii, Nev.

In accordance with LCD L28288, Facet Joint Denervation requires placement of a needle in the facet joint under fluoroscopic or CT guidance. This requirement is effective for dates of service on or after Sept. 2, 2008, in California, Nevada and Hawaii.

LCD 28288, MLN Matters Number: MM6960; CMS Pub 100-04

Age-appropriate code for end stage renal disease (ESRD) services


RAC Region D

The beneficiary's age at the end of the month is the age of the patient for determining the appropriate age based ESRD-related services code.

CMS Pub 100-04


About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

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