Revenue Cycle

Q&A: Medical record request limit calculations

Recovery Auditor Report, April 30, 2009

Q: We have been trying to calculate the outpatient hospital medical record request limits. According to RAC published info, the limit is 1% of paid services up to 200 per 45 days. How is a paid service determined? What data is CMS using to determine this? We've asked our CMS RAC project leader but have gotten no response. Can you help?
A: The medical records limits are based upon your hospital’s 2007 Medicare statistics, and for outpatient hospitals the number is based upon “services.” In the CMS RAC Part B Open Door Forum held April 14, CMS representatives indicated that a “service” was equivalent to a line item (i.e., each procedure or service performed). For example, if your hospital had 360,000 paid Medicare services in 2007, that number would be divided by 12 to obtain your facility’s average monthly services billed to Medicare. In this example, the average would be 30,000 (outpatient) services per month. Multiply that number times the 1% RAC medical records request limit, and you arrive at a figure of 300 outpatient medical records that can be requested in a 45-day period. However, the RAC medical record limit is 200 records per 45 days.
According to an April 20th Member Advisory issued by the American Hospital Association (see above for more information on the Member Advisory), a hospital with a single NPI number would be subject to a total medical record limit of 200 per 45 days, including inpatient, outpatient and inpatient rehab facility claims.
Stay tuned to your RAC for further clarification on medical records request limits based upon the number of NPI numbers at your facility, and the storage location of medical records. According to a clarifying statement published with the transcript of the CMS RAC Part A Open Door Forum held April 8, there is a limit of 200 medical records for both inpatient and outpatient records in the same 45-day period “provided the medical records for Part B services are located in the same medical record room.” 
Editor’s note: Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc., answered this question.

Most Popular