Part B Insider (Multispecialty) Coding Alert

Published on Wed Jul 26, 2006 PDF

Learn which procedures are catching the eyes of the RACs

Surgical practices, beware: The Recovery Audit Contractors (RACs) are starting to zero in on some procedures that your doctor may be performing.

The RACs receive payments based on the amount of overpayments and underpayments they discover in your practices. So far, RACs are searching for physician  payment errors in New York, California and Florida, but observers expect them to expand to other states.

One internal medicine practice in California reports that it has received requests for information on 145 procedures from its ambulatory surgery center that practices gastrointestinal endoscopy.

Most of these requests were for procedures involving:

- colonoscopies with biopsies (45380),
- colonoscopies with snare (45385),
- colonoscopies w/ ablation (45383),
- diagnostic colonoscopies   (45378), and
- screening colonoscopies: G0121 or G0105 (high risk).

The RACs also asked for information on 10 to 15 esophagogas-troduodenoscopies (EGDs), says a coder with the practice. Seven weeks after sending in all the requested information, the practice hasn't heard back. The RAC's staff told the practice's manager that because the RACs are a -pilot program,- there's no telling how long it will take to respond.

Meanwhile, another California practice has received a number of requests for information about epidural injections. In all cases, the practice had billed epidural code 63211 with facet joint injection codes 64475 and 64476.

In fact, a coder at the practice looked at those epidural claims and found that the practice had billed them incorrectly - but the practice would have received more money if it had billed them the right way. Instead of billing for multiple levels of the spine, the practice had mistakenly billed too many times for the same level, the coder says.

In one instance, the RAC sent 200 requests at once - but they all turned out to be requests for the same claim, the coder says.

Give Them What They Want

What to do: If a RAC requests your medical records, don't play for time, say experts. You should send in the requested files as quickly as possible.

Also, you should send in as much documentation as possible the first time around, urges attorney Michael Manthei with Holland & Knight in Boston. That way, the RAC will go away sooner. -If they have to keep coming back for additional documentation the process gets even more drawn out,- Manthei warns.

Some providers may believe that if they only provide a limited amount of documentation, the RAC will go away, but the RACs have a financial incentive to come after you until they collect money, Manthei warns.

No do-overs: If the RAC requests records and you discover an error in the documentation, don't try to correct the records before you send them in, Manthei warns. -It could be viewed as potentially criminal,- he adds.

Instead, you can send in the records as-is, but include your corrections in a cover letter or an added exhibit.