Health Information Management

CMS says medical necessity, physician complex audits on their way

HIM-HIPAA Insider, June 1, 2010

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On the May 12 RAC 101 call for physicians, a caller asked CMS specific information about when medical necessity and physician reviews would begin. A CMS representative instructed the audience that the physicians are already undergoing automatic reviews but the complex reviews requiring medical record requests won’t begin until CMS posts record requests limits on its RAC website.

In terms of medical necessity audits, at least one RAC has submitted a medical necessity issue to CMS for approval, according to a CMS representative on the call. CMS has not yet approved any proposed medical necessity issues but anticipates doing so in the near future.
Below is a transcription from this portion of the Q&A session:
Q: Do you have an anticipated start date for the physician reviews as well as the medical necessity reviews?
A: There are some physician reviews going on—automated, just not [those requiring] medical record requests [i.e., complex reviews]—and we would assume those would start happening once we have the additional documentation limits, which, again, I believe our managers and other higher-ups in the program are working on developing. We would hope they would be out sometime shortly. It really shouldn’t be too long. As far as medical necessity, those reviews are just beginning, in their very early stages.
Q: Do you mean getting ready to be posted as approved issues?
A: Actually, [medical necessity issues are] coming in. I’m not sure [RACs have] them posted on their websites, but we are getting the new issue proposals into CMS in order to approve them as issues.
Editor’s note: For the latest information on RAC-approved issues and news, visit the Revenue Cycle

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