AMA: Stop Medicare RAC Audits


Government audits of physicians' Medicare evaluation and management (E&M) coding "will undoubtedly lead to erroneous recoupments and lengthy, expensive appeals" for both doctors and the government, the American Medical Association contends in a letter to Centers for Medicare & Medicaid Services (CMS) Acting Administrator Marilyn Tavenner.   

The letter urges CMS to rescind its authorization for Recovery Auditor Contractor (RAC) Connolly, Inc. to begin auditing Medicare coding for CPT 99215 – evaluation and management of an established patient – in physician offices in Texas and several other states.     

The AMA letter says "physician choices regarding appropriate code designation can be a subjective matter based on the complexity of the patient visit. Physicians who provide E&M care apply complex decision-making based on myriad clinical approaches, including research and review of patient medical history, analyses regarding appropriate medication, discussion of home situation and prescription distribution plan, preventive care planning, and many other variables. 

"Based on our historical experience with the RACs, and in light of the fact that the RACs are not required to have same-specialty physicians review RAC determinations, we have no confidence that the RACs will be up to the task of understanding these variables or their clinical relevance." 

TMA Payment Advocacy Director Genevieve Davis says TMA is concerned that Connolly will extrapolate its findings based on a statistical sample of claims, which is not always an accurate assessment of a physician's coding and documentation. She says TMA has expressed that and other concerns about the impending audits to both Connolly and the regional CMS staff but neither has responded. 

The AMA letter says allowing Connolly to extrapolate its findings "based on a sample of CPT code 99215 claims is misguided and should be rescinded. Each E&M visit is different based on the unique needs of the patient." 

TMA Payment Advocacy says you have options if Connolly selects you for an audit.  

TMA Ready to Help
TMA offers several online courses and publications to help you avoid trouble. They also offer continuing medical education (CME) credit. They include: 

For a complete list of offerings, go to the TMA Education Center. It's a convenient, one-stop access to CME when you need it.  

TMA's Coding Hotline can answer your questions. Call (800) 880-1300, ext. 1414. 

 TMA Practice Consulting advises you against waiting for a formal third-party or RAC audit. Be proactive. Find out if you or your practice is at risk for an audit. TMA Practice Consulting has certified professional medical auditors and coders on staff to review physicians' documentation to determine if you are following documentation guidelines, correctly coding levels of service, and establishing medical necessity. It also offers these services to help make sure you code correctly and document what you've done:  

  • Coding and documentation audits, comprehensive reviews of medical record documentation to identity opportunities for improvement, helping reduce liability and risk of third-party audits;  
  • Coding and documentation trainingin-depth instruction on the coding and documentation guidelines and criteria for appropriate charge capture; and 
  • Coding and documentation check-ups, abbreviated reviews of claims coding and medical record documentation to provide a glimpse into a physician's coding techniques.  

Call TMA Practice Consulting at (800) 523-8776 for a proposal, or email  

CMS also has resources for physicians. They include the Evaluation and Management Services Guide and Documentation Guidelines for Evaluation and Management Services. Physicians should follow these guidelines; auditors use them when reviewing medical records. They're also the guidelines that electronic health record vendors should use when setting up physician templates. Physicians should make sure their vendor does this. 

 Action, Oct. 1, 2012