Revenue Cycle

CMS releases transmittal on RACs and LCDs

Recovery Auditor Report, September 17, 2009

CMS released on September 11 transmittal 302, which outlines the authority RACs, MACs, and other Medicare auditors have to apply exceptions to certain local coverage determination (LCD) clinically reasonable and necessary requirements. According to CMS, such exceptions should be rare and only under unusual circumstances.
The transmittal notes that during complex medical reviews certain auditors (e.g., MACs, RACs, and CERT) must apply LCDs made by fiscal intermediaries, carriers or MACs. However, in rare and unusual circumstances it may become necessary during such a review to apply an exception to the clinical criteria in applicable LCDs after a thorough review of the patient’s medical record and a comprehensive analysis of the evidence in medical literature.
Contractors other than RACs may apply an exception to either approve or deny a claim. RACs, however, may only use the exception not to deny the claim, according to the transmittal. Note also that exceptions may not be made for insufficient or missing documentation, and auditors may not make exceptions to national coverage determinations, MAC articles, or CMS manuals.
The changes are effective October 13.

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