CMS/RAC Begin Audits of Medicare Physicians’ Use of CPT Codes

The Audits are coming and they could cost you BIG!

CMS, the Centers for Medicare and Medicaid Services, has just approved audits of Physician’s offices in Medicare Region C.

Connolly Inc., the Medicare Region C Recovery Auditor, will begin auditing Medicare Physicians in 15 states as well as Puerto Rico and the U.S. Virgin Islands through “complex review”, which entails human review of medical records or other documentation, going as far back as 10-01-07. They will be looking primarily at the use of CPT code 99215 in Medicare billing and will be allowed to extrapolate their findings based on statistical samples. Extrapolation consists of a statistical sampling of Medicare claims where that code was used and finding a rate of occurance of overpayment or underpayment of Medicare claims that is then applied to all instances. It is important to note that the overpayment of less than $10 per Medicare claim is not allowed to be recovered or aggregated for recovery unless extrapolation is used.

The American Medical Association, AMA, has strongly objected to these audits calling them a “bounty hunter-like program” and saying that they will create an “in terrorem” effect forcing conservative billing by Medicare physicians.

Connolly is a fee for service RAC contractor. RAC contractors are private entities retained by the government to identify overpayments or underpayments and to return or collect monies accordingly.

The states being audited are; AL, AR, CO FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, and WV.

For more information click here to go to the AMA website.

To read the letter that the AMA sent to the Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services click here.

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