Health Information Management

News: Special MLN points to documentation concerns raised by RAC

CDI Strategies, July 22, 2010

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A special edition MLN Matters article released last week points to two common reasons for RAC claims denials—lack of timely submission of requested documentation and lack of documentation supporting medical necessity.

On July 12, CMS released what it called “the first in a series of articles that will disseminate information on RAC high-dollar improper payment vulnerabilities.”
While CMS provided a list of requirements to assist providers in ensuring the timely submission of sufficient documentation to justify the services billed, the question of whether physician queries must be submitted remains unanswered. (Read the article “CMS offers partial answer to RAC query submission questions”in CDI Strategies and “RAC request queries as complex reviews roll out”in The CDI Journal.)
At least one statement in the MLN Matters article suggests that RACs may be requesting query forms, says Kimberly Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc. The statement says:
 “RACs must clearly indicate in ADR letters suggested documentation that will assist them in adjudicating the claim.”
“It’s interesting that CMS calls the information requested by the RAC ‘suggested documentation,’ because there’s been an issue of whether or not coding queries have to be submitted,” she says. “CMS stated on an implementation call that these queries only have to be submitted if they supported a claim, and this seems to be in line with that.”
To view special edition MLN Matters article SE1024, visit the CMS website

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