RAC Audits and Prepayment Reviews that Orthopedic Practices Should be Aware of

by | Last updated Jul 4, 2023 | Published on Jun 13, 2014 | Medical Billing

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Several important developments have occurred in the U.S. healthcare system during the past year such as the Affordable Care Act, modifications to ‘Use-or-Lose’ Rule for FSAs and so on. These developments had an impact on various crucial tasks associated with healthcare practices such as medical coding, billing and revenue cycle management in their own way. Here are some key developments pointed out by the American Association of Orthopedic Surgeons (AAOS) that orthopedic practices must take note of.

RAC prepayment Reviews

Since the CPT codes 99205 and 99215 have been identified as one of the top 15 codes for improper payment rates, National Government Services (a Medicare recovery audit contractor (RAC)) has decided to conduct service-specific prepayment reviews of CPT codes 99205 and 99215 for the claims submitted to Jurisdiction 6 Part B for Illinois, Minnesota, and Wisconsin. If you are among the providers whose claims are being reviewed, you will receive a request soon for additional documentation. You will have to submit the requested documentation within 30 days from the date specified in the request letter. However, (AAOS) has recommended to the Centers for Medicare & Medicaid Services that RACs should not be allowed to audit these Evaluation and Management codes.

The Benevolent Gesture Medical Professional Liability Act

The Benevolent Gesture Medical Professional Liability Act was signed into law by Pennsylvania Gov. Tom Corbett. This law protects any action, conduct, or statement that expresses a sense of apology, condolence, explanation, compassion, or commiseration “emanating from humane impulses”; factual statements or admissions of guilt for a medical outcome or error are not covered. With this, hospitals, long-term care facilities and physicians in Pennsylvania can now offer expressions of sympathy to patients in case of poor medical outcome without having the fear of those words being used by others against them in future litigation.

Physicians Can Now Own Physical Therapy

Thanks to the passage of Assembly Bill (AB) 1000, a licensed medical corporation in California can legally employ physical therapists (PTs) and other healthcare professionals from January 1, 2014. This bill was cosponsored by the California Orthopedic Association, the California Medical Association, and the California Physical Therapy Association. The provisions of this law are as follows.

  • Patients can seek treatment directly from a physical therapist. There is no need for being evaluated by a physician at first for a limited period of time (45 days or not more than 12 visits).
  • No modifications or extensions to the scope of practice for PTs. The law supports that they are not authorized to carry out a medical diagnosis.
  • The patient should be referred quickly for an in-person examination by a physician if the patient’s condition is beyond the scope of PT and there should be a clarification that the insurer need not pay for the services offered by the PT without a medical diagnosis.
  • Natalie Tornese
    Natalie Tornese
    CPC: Director of Revenue Cycle Management

    Natalie joined MOS’ Revenue Cycle Management Division in October 2011. She brings twenty five years of hands on management experience to the company.

  • Meghann Drella
    Meghann Drella
    CPC: Senior Solutions Manager: Practice and RCM

    Meghann joined MOS’ Revenue Cycle Management Division in February of 2013. She is CPC certified with the American Academy of Professional Coders (AAPC).

  • Amber Darst
    Amber Darst
    Solutions Manager: Practice and RCM

    Hired for her dental expertise, Amber brings a wealth of knowledge and understanding of the dental revenue cycle management (RCM) services to MOS.

  • Loralee Kapp
    Loralee Kapp
    Solutions Manager: Practice and RCM

    Loralee joined MOS’ Revenue Cycle Management Division in October 2021. She has over five years of experience in medical coding and Health Information Management practices.