RAC E/M Code Audits

CMS recently approved a request by the Recovery Audit Contractor (RAC) for Region C, Connolly Consulting Associates, to perform reviews for incorrect billing of evaluation and management claims. At the present time, this will focus on CPT code 99215 according to CMS. The Connolly website describes this review as a “Limited Review – Statistical Sampling on Evaluation and Management claims to calculate and project incorrectly paid claims.”

Part B News reports that Connolly has selected a small number of providers with a high utilization of 99215 claims for reimbursement. The results of this review will likely set the stage for additional reviews by Connolly, as well as the remaining three RACs. Of particular concern is the RAC’s ability to extrapolate the overpayment based on the findings of a small sample. RACs are able to “look back” three years. An error rate of 10% on the small sample could result in a demand letter for recovery of what they believe to be an overpayment for the universe of claims filed with 99215 over the three years.

Would your 99215s pass a review? Do you know your utilization of 99215s in comparison to your peers? Corcoran Consulting Group can assist with answering both of these questions. This may be a good time to get ahead of the RAC auditors and determine your practice’s level of risk in this area. Call us at 800-399-6565 or email to help@corcoranccg.com for assistance.