The Centers for Medicare & Medicaid Services (CMS) recently released new additional documentation request limitations for the Medicare Recovery Audit Contractor (RAC) program in fiscal year (FY) 2010.
According to the new document released by CMS, the limits will be set on an annual basis to establish a cap "per campus" on the maximum number of medical records that may be requested per 45-day period.
In brief, some of the highlights of the new document include:
Campus Unit. CMS states that a "campus unit...may consist of one or more separate facilities/practices under a single organizational umbrella" and that the limits will be based on the servicing provider/supplier's Tax Identification Number (TIN) and the first 3 positions of the ZIP code where they are physically located. CMS provides the following examples:
- Provider A has TIN 123456789 and 2 physical locations in ZIP codes 12345 and 12356. The 2 locations would qualify as a single campus unit.
- Provider B has TIN 123456780 and is physically located in ZIP codes 12345 and 21345. In this case, the provider would be considered 2 distinct entities for additional documentation purposes, and each location would have its own additional documentation limit.
Limit Per Campus. CMS reports that limits will be set at 1 percent of all claims submitted for the previous calendar year (2008), divided into 8 periods (45 days). A provider's limit will be applied across all claim types, including professional services. CMS provides the following examples:
- Provider C billed 156,253 claims last year. The provider's additional documentation limit would be (156,253 * .01)/8 = 195.31 or 195 additional documentation requests per 45 days.
- Provider D billed 50,000 inpatient claims, 75,000 outpatient claims, 20,000 SNF covered stays, 20,000 home health episodes of care, 250,000 physician claims, 10,000 inpatient rehab claims and 1,000 hospice claims. The provider's additional documentation limit would be (426,000 * .01)/8 = 532.5 or 532 additional documentation requests per 45 days, if no cap is in place (see below).
RAC Discretion. RACs "may exercise discretion in the exact composition of an additional documentation request." As an example, CMS states that a RAC may request inpatient records up to the full limit even though the provider's inpatient business may only be a small portion of their total claim volume.
FY 2010 Caps. According to CMS, 2 caps will exist in FY 2010. CMS describes the 2 caps as follows:
- Through March 2010 - The cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers.
- From April 2010 through September 2010 - Provider/suppliers that bill in excess of 100,000 claims to Medicare (per TIN, across all claims processing contractors) will have a cap of 300 additional documentation requests per campus unit, per 45 days.
However, the new document indicates that, after the first 6 months of the fiscal year, RACs will be allowed to request permission from CMS on a case-by-case basis to exceed the cap. CMS reports that an expanded cap will not be automatic and that affected providers will be notified before receiving additional requests.
For additional information, see the new document addressing the additional documentation request limits. CMS also reports that questions can be directed to RAC@cms.hhs.gov
CMS reports that it will post the limits for all other reviews at a later date.
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