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Since I am an advocate and consultant for the provider community, it’s important for me to recognize a common misconception that RAC contractors are focusing purely on automated audits of hospital services.

Being labeled “rural, independent or small” doesn’t divorce providers from the likelihood of a RAC audit. Regardless of employment status, clinic size or demographic, if you are a participating provider, they have access to your data.

In fact, as the American Medical Association (AMA) makes changes to CPT® services, RACs have clued into potential billing issues tied to timing and code changes. Looking back to November 2009, Issue D000482009 HDI, Not a New Patient, was very timely due to the elimination of the consultation codes (CPT 99241-99245 & 99251-99255 for CMS providers. Nearly two years later, this continues to be a lucrative area of review. Although The Centers for Medicare & Medicaid Services (CMS) has defined the new patient rule clearly within the Medicare Claims Processing Manual (Chapter 12, Section 30.6.7), (1) specialty providers continue to code using the old consultation guidelines. New and established evaluation services are designated as such using the three-year rule, specialty designation and tax identification. Consultations did not have new or established designation, which allowed providers to use these codes based on new problems without considering the issue of timing. Furthermore, the RVU differential was significant as compared to the new patient category, thus incentivizing providers to use these codes if documentation met criteria standards.

The ability to translate your own claims data to identify Medicare beneficiaries with multiple new patient services within a three-year period will help reduce the opportunity for RACs to make this discovery instead.

More recently, on June 23 Region C published another evaluation- and management-related issue. “Evaluation and management services with allergy services” appears to be a straightforward description, yet it may translate into other “medical necessity” areas. Allergy services alone often include a host of tests and injections exclusive of E/M codes. Likewise, the use of Modifier 25 (separately identifiable E/M the same day as procedure or service) plays a significant role in the documentation of additional E/M service.

Looking back five years ago, CMS issued several alerts and CERT reports for CPT 99211. Although this is a “minimal” evaluation and management service not requiring the presence of the provider, medical necessity remains key. Within national CERT findings, 99211 was being used in several instances when only an injection procedure was performed and no other service was documented for a given day. Allergy injections run parallel to these findings. More often than not allergy injections are pre-scheduled and no other services beyond the injection are scheduled. The injection code includes the minimal amount of work needed to make the determination that the patient is fit to undergo the procedure.  On the other hand, if the patient has a significant, separately identifiable problem that meets the requirements of an E/M service, this may be billed using Modifier 25 for claims processing.

CMS has become increasingly sophisticated with regard to data mining and detecting modifier misuse. The bigger picture focuses on evaluation and management services tied to typically scheduled services. Injections of all types are an easy target for the RACs, as they frequently are scheduled in series and do not require the presence of a physician or mid-level practitioner.

As a precautionary audit within your own practice, review procedures and services that are pre-scheduled and develop a report to determine how often E/M services are billed in conjunction. If this is found to occur frequently, pull the documentation and compare the “visit intent” against the note content. This type of internal control should be run quarterly and shared with the medical staff to provide education and training to avert potential RAC scrutiny.

About the Author

Jana B. Gill, MA, CPC, is currently a product engineer and developer for regulatory and reimbursement software suites for Wolters Kluwer Company. Her expertise in coding and compliance has been integral to client and product development.  Jana has more than eighteen years of experience in healthcare, including coding, compliance, mergers and acquisitions, physician integrations and healthcare litigation. She is a national speaker for chapters of the MGMA, AAPC and Wolters Kluwer Company.

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(1) “A patient who has not received any professional services – i.e., evaluation and management service or other face-to-face service (such as a surgical procedure) – from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a three-year time-period, i.e. a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

CMS Heat is on – Hence the RAC Attack


Jana Gill, MA, CPC

Jana B. Gill, MA, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services.

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