CMS to Pilot Controversial RAC Audits Targeted at 99215 CPT Code

The Centers for Medicare & Medicaid Services’ Recovery Audit Contractor (RAC) program will pilot a series of audits to examine the use of the CPT evaluation/management code 99215 by physicians.

The auditing program pilot has not been officially announced, but medical associations have been warning their membership of it since early September.

“We have been informed that in the next several weeks, Connolly, the RAC contractor for Medicare Region C, will begin complex medical review of CPT code 99215 for a Level 5 office visit, and will be permitted to extrapolate their findings based on a statistical sample of such claims,” wrote Dr. James Madara of the American Medical Association  in a Sept. 11 letter to CMS. “The AMA strongly opposes RAC review of E&M [Evaluation & Management] codes, including CPT code 99215, and strongly urges CMS to rescind its approval of RAC review of CPT code 99215 and reject any other pending RAC requests to audit E&M codes.”

The audit pilot will be conducted in CMS’s Region C, which includes the states of Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia, as well as Puerto Rico and the U.S. Virgin Islands.

The timing of the RAC pilot coincides with an extended investigative series by the Center for Public Integrity  that reported marked increases by physicians in the use of CPT codes 99214 and 99215, for which Medicare reimburses at the highest rates. The Center report followed an investigation by the U.S. Department of Health & Human Services’ Office of Inspector General who reported similar findings, although on a far lesser scale than the Center for Public Integrity, which concluded that Medicare had paid $11 billion in “questionable” fees. The OIG report focused on the 1,700 physicians nationwide who “billed higher level, more complex and expensive E/M codes in 2010 at least 95 percent of the time.” OIG did not speculate what percentage of feels by those physicians were “questionable,” but the total paid for codes 99214 and 99215 was $108 million.

According to OIG, the report was the first of many into coding and billing practices. “We did not determine whether physicians who billed higher level E/M codes in 2010 billed inappropriately,” OIG wrote. “Subsequent evaluations will determine the appropriateness of Medicare payments for E/M services and the extent of documentation vulnerabilities in E/M services.”

The OIG report offered three recommendations to CMS. “CMS concurred with our recommendations to (1) continue to educate physicians on proper billing for E/M services and (2) encourage its contractor to review physicians’ billing for E/M services,” wrote OIG. “CMS partially concurred with our third recommendation, to review physicians who bill higher level E/M codes for appropriate action.”

While the pilot program will focus on the south, the American Academy of Family Physicians has warned its membership that “physicians in other states should be on alert, as well, because the E/M code audit process is scheduled to be expanded to the other three RAC regions.”

For those interested in preparing for a RAC audit, the Physicians Advocacy Group published a detailed white paper on what to do before, during, and after you are audited. You can find it here.