AHA Coding Clinic® for HCPCS - 2013 Issue 1
Recovery Audit Program and Recovery Audit Contractors Update
We are sure that everyone is quite familiar with the Recovery Audit Program and the Recovery Audit Contractors (RACs) by now. Our first article was published (Third Quarter 2009) as the reviews were in their beginning stages. This article is intended to provide an update on some of the issues approved by the Centers for Medicare & Medicaid Services (CMS) for review over the past year. Some of the regional information was revised in 2012. Following is a listing of the regions and updated contractor information: Region A Performant Recovery, Inc., formerly Diversified Collection Services, Inc., of Livermore...
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Article Overview
This article provides a Medicare Recovery Audit Program update for coding and compliance professionals. It summarizes regional Recovery Audit Contractor information, describes the semi-automated review process, and outlines broad categories of CMS-approved review issues spanning claim submission, unit reporting, diagnosis support, modifiers, and procedure reporting. The content is useful for readers tracking RAC activity, audit focus areas, and the types of billing patterns that have drawn review attention.
Why This Topic Matters
RAC activity can affect claims review, documentation expectations, and compliance monitoring. Understanding the scope of review topics helps providers, coders, auditors, and billing teams anticipate audit focus areas and identify claims that may warrant internal review.
Article Sections
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Program update and review context
Introduces the Recovery Audit Program update and explains that the article focuses on CMS-approved review topics and recent changes to RAC information.
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Regional contractor information
Lists the RAC regions and the contractor organizations associated with each region, along with broad geographic coverage and contact details.
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Semi-automated review process
Describes the two-part review process used in the program and the general purpose of claims-based review and provider notification.
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Issues under review
Summarizes the main categories of review issues discussed in the article, including medical necessity, unit reporting, bundling, diagnosis support, modifier use, treatment frequency, and stand-alone reporting concerns.
What You Will Learn
- How the Recovery Audit Program update is organized
- What the article says about regional RAC contractor coverage
- How the semi-automated review process is described at a high level
- Which broad audit issue categories are being reviewed
- Why certain billing patterns may draw RAC attention
Who Should Read This
- Medical coders
- Compliance staff
- Billing staff
- Revenue cycle professionals
- Healthcare auditors
- Physician practice managers
- Hospital coding teams
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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