Recovery Audit Contractors (RACs) to Begin Auditing Medicare Claims in October

After a three-year demonstration project, Medicare Recovery Audit Contractors (RACs) will begin audits this fall that include ASHA member services. The RACs were mandated by the Tax Relief and Health Care Act of 2006 to identify improper payments made on health care services claims.

Audits of interest to speech-language pathologists have been approved for RAC Regions C-South and D-West for late summer/fall by the Centers for Medicare & Medicaid Services (CMS);claims paid on or after October 1, 2007 will be screened in an automated process to detect when "untimed" procedure codes were billed more than once per day. The common speech-language pathology codes for evaluation and treatment of speech-language and dysphagia disorders are untimed, meaning that the code as one unit represents a session, regardless of the session length. While the RACs are free to examine most outpatient settings, including physician practices, hospital clinics will be the main focus. According to an earlier CMS demonstration project, hospitals have been lax in establishing edits to identify faulty claims and have not adequately trained practitioners in coding.

The states will initially be limited to: Region C-Alabama, Florida, Georgia, and South Carolina;and Region D-Arizona, Montana, North and South Dakota, Utah, and Wyoming. Additional information on the audits can be found on the CMS Web site.

Audiologists should also be ready for RAC audits. During the demonstration project RACs recovered $1.4 million for overpayment of vestibular function testing in Florida.

Audiologists and speech-language pathologists should review their documentation and coding policies in light of the RAC audits. Use ASHA's coding resources, guidelines and policy statements for assistance in preparing claims. A comprehensive resource available on ASHA's Web site is Services Medicare CPT Coding Rules for Audiology and Medicare CPT Coding Rules for Speech-Language Pathology Services.

The current RACs are contracted to receive a bounty of 9 to 12.5% of the overpayments collected and underpayments found. For further information, contact Mark Kander, ASHA's Director of Health Care Regulatory Analysis, at mkander@asha.org or 301-296-5669.