RAC To Target High-Level E/Ms
By Justin Vaughn, M.Div, CPC
Director of Compliance

9/17/2012

According to the Medical Group Management Association (MGMA), the Centers for Medicare & Medicaid Services (CMS) has authorized the Region C RAC (Recovery Audit Contractor) to undertake the targeted review of level-5 evaluation and management (E/M) services. The states falling under the aegis of this regional RAC are: Ala., Ark., Colo., Fla., Ga., La., Miss., N.M., N.C., Okla., S.C., Tenn., Tex., Va., and W.Va.

In other words, providers who perform E/M services in these states will soon be subject to having their records reviewed whenever they bill a level-5 service, such as 99205 (new patient encounter) or 99215 (established patient encounter).  Chronic pain providers should therefore double their efforts to support such claims with appropriate documentation.  Specifically, physicians must endeavor to:

• Hit all of the required history, exam and medical decision-making (MDM) documentation bullets, as outlined by HCFA’s (now CMS) 1997 Documentation Guidelines for Evaluation and Management Services.

• Denote the medical necessity rationale for the level-5 service.  Was such a high-level service really warranted? You may hit all the required documentation bullets for a level-5 E/M, but if all the patient complained of was a hangnail, the RAC auditor will ask you to repay the government.

The reason I bring this issue to your attention is because I have spoken with so many pain physicians throughout the country who revealed that they routinely or even exclusively submit high-level E/M claims.  Their rationale is that a preponderance of their patients are older with a whole panoply of problems, disorders and syndromes.  This may be, but this does not remove the target that is now squarely on your back. Therefore, proceed with greater caution; be even more judicious when selecting the appropriate code for the service performed; and make sure you are familiar with the 1997 Guidelines, as referenced above.  (A copy can be obtained from this CMS website.)  In addition, you should seek to distill these documentation requirements down to a bulleted template format for ease of use.)

In the event of a RAC audit of your pain practice, your record documentation is everything.  Therefore, make sure your claims for high-level services especially are sufficiently supported and invariably justified.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.