Revenue Cycle

CMS to expand 2010 additional documentation requests limits

Recovery Auditor Report, February 18, 2010

In response to feedback from the RACs, providers, suppliers and their associations, CMS expanded its fiscal year 2010 RAC additional documentation requests (ADR) limits to all institutional providers.

According to CMS, each RAC will set an annual limit on the maximum number of medical records that can be requested per 45-day period, per hospital campus. A campus unit is defined as a group of facilities or practices grouped under one single organization. For each campus, the limit is on that unit’s prior fiscal year Medicare claims volume.

The previous system for establishing ADR limits was based on National Provider Identifiers (NPI), a 10-digit number adopted in 2004 as the HIPAA standard identifier. Covered healthcare providers, health plans, and healthcare clearinghouses used NPIs in administrative and financial transactions. The problem with NPIs was that a provider may have multiple NPIs and be subject to maximum medical records on each, according to Elizabeth Lamkin, anassociateat Axcel Healthcare Group in Tampa, FL. CMS addressed the issue after the volume of concern expressed by providers in CMS forums, she notes.

New ADR limits are based on the provider or supplier’s Tax Identification Number (TIN) and the first three positions of the facility’s ZIP code. These TINs will reduce the number of limits that would have been imposed for each facility by using NPIs as the standard identifier. The limits will be set at 1% of claims submitted for the previous calendar year, and divided into eight 45-day periods. CMS clarified that limits will be applied for all claim types, including professional services.

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