RAC Audit: Therapeutic, Prophylactic, and Diagnostic Injections and Infusions
The Recovery Audit Contractors (RAC) initiative was developed by the Centers for Medicare and Medicaid Services (CMS) to fight fraud and abuse in the Medicare program. Recovery Audit Contractors review claims post-payment, with the goal of identifying and correcting past improper payments.
In June 2019, “Therapeutic, Prophylactic, and Diagnostic Injections and Infusions: Documentation Requirements” was approved as a RAC topic. This was referred to CMS as part of the Targeted, Probe and Educate (TPE) review process. Issues included providers with potential outlier billing (such as increased frequency or an excessive number of units) of CPT code 96365 (IV infusion, therapeutic, up to 1 hour) over the past 6 months, missing Medication Administration Records (MARs), absent start/stop times, and incorrect billing of CPT codes 96365 (IV infusion, therapeutic, up to 1 hour) and 96366 (infusion, each additional hour, therapeutic) when the minutes did not support the required time.
While documentation to support each claim should be kept on file, it will only need to be submitted when an additional documentation request (ADR) is received requesting such documentation for review. Documentation will be reviewed to determine if correct billing, coding, and medical necessity guidelines for Therapeutic, Prophylactic, and Diagnostic Injections and Infusions were met.
If a provider or practice is audited, there are several opportunities to appeal. The “Medicare Parts A & B Appeals Process” provides a detailed guide on the process.
Questions regarding billing, coding, and reimbursement may be sent to ASCO staff at email@example.com.