“We have been informed that in the next several weeks, Connolly, the RAC contractor for Medicare Region C, will begin complex medical review of CPT code 99215 for a Level 5 office visit, and will be permitted to extrapolate their findings based on a statistical sample of such claims,” the AMA notes in a recent letter to CMS Acting Administrator Marilyn Tavenner. “The AMA strongly opposes RAC review of E&M codes, including CPT code 99215, and strongly urges CMS to rescind its approval of RAC review of CPT code 99215 and reject any other pending RAC requests to audit E&M codes.”
Physician choices in E&M codes can be a subjective matter based on the complexity of a patient visit, and “we have no confidence that the RACs will be up to the task of understanding these variables or their clinical relevance,” the AMA contends. “We note that RACs have a low accuracy rate as it is: CMS’ FY2010 Recovery Auditor Report to Congress reported that 46 percent of the Medicare RAC determinations appealed were decided in the provider’s favor. RAC review of E&M codes will undoubtedly lead to erroneous recoupments and lengthy, expensive appeals for both physicians and CMS.”
AMA also reminds CMS of government initiatives, such as reporting of quality measures and electronic health records meaningful use, that encourage more complex care be provided for more complex patients. “To penalize these same physicians for billing at the CPT code that often best reflects the care that these patients require is short-sighted and inequitable.” The complete AMA letter to CMS is available here.