Orthopedic Coding Alert

Question: I've been doing some reading about recovery audit contractors (RACs), and frankly it scared me. With all of the compliance hurdles for correct Medicare coding, the last thing I need is to have to worry about is someone picking my claims apart after we've been paid. I do want to code everything correctly, though, and I certainly don't want to get into the habit of refunding Medicare for running afoul of a RAC. So, could you give me a primer on RACs and how I should deal with them?

Maine Subscriber

Answer: RACs are independent contractors that data-mine Medicare claims, review them for errors, and collect contingency fees based on the amounts they recover. Because of how they are paid, RACs are incentivized to go after coding and billing errors that are so common and widespread that they will be paid handsomely for discovering (and recovering) overpayments.

Currently, there are four RAC regions of the United States. Generally, Performant Recovery, Inc. reviews providers in the northeastern U.S., HMS Federal Solutions handles the west, and Cotiviti covers much of the midwestern and southeastern parts of the country.

Resource:  Go to this CMS map to find your RAC region and the RAC assigned to your region:https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Medicare-FFS-RAC-map-November-2016-clean.pdf.

On their web sites, the RACs disclose issues that CMS has approved them to audit. Here are the links to each RAC's "audit issues" page, which contain details about what the RAC is currently looking for.

Performant: https://performantrac.com/audit-regions/region-1/
HMS: https://racinfo.hms.com/Public1/NewIssues.aspx
Cotiviti: http://www.cotiviti.com/healthcare/who-we-serve/cms-approved-issues

Ortho-specific RAC target: There is at least one recent RAC announcement that is sure to concern orthopedic coders. In a September announcement, Performant reported that CPT^® code 29822 (Arthroscopy, shoulder, surgical; debridement, limited) is not separately payable when billed along with a shoulder arthroscopy procedure performed on the same shoulder on the same day. All three RACs are auditing claims for this problem.

Performant's website states that you are forbidden from reporting 29822 with any of the following codes - if the provider performs the services "on the same shoulder for the same day for the same beneficiary at the same encounter":

• 29805, Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)
• 29806, Arthroscopy, shoulder, surgical; capsulorrhaphy
• 29807, ... repair of SLAP lesion
• 29819, ... with removal of loose body or foreign body
• 29820, ... synovectomy, partial 
• 29821, ... synovectomy, complete
• 29823, ... debridement, extensive
• 29824, ... distal claviculectomy including distal articular surface (Mumford procedure)
• 29825, ... with lysis and resection of adhesions, with or without manipulation
• 29827, ... with rotator cuff repair
• 29828, ... biceps tenodesis.

Note: This is just one potential RAC audit area that your practice might want to brush up on. For more specific RAC information, check out the website of the RAC in your region.