RAC Audit


Recovery Audit Contractor (RAC) Audits

RAC audits have resumed, however due to the ongoing COVID-19 PHE  the RAC contractor is temporarily limiting reviews to dates of service preceding March 1, 2020.

Current Items/Services Under a RAC Review  as of 01/01/2021

Cervical Orthoses: An automated review to determine if reasonable useful lifetime (RUL) requirements were met. Affected codes include L0112, L0113, L0120, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0220, L0700, L0710, L0810, L0820, L0830, L1000, L1001, L1005, L1200, L1300, L1310, L1499.

AFO/KAFO: An automated review to determine if reasonable useful lifetime (RUL) requirements were met. Affected codes include L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4631

Upper Extremity Orthoses: An automated review to determine if reasonable useful lifetime (RUL) requirements were met. Affected codes: L3650, L3660, L3670, L3671, L3674, L3675, L3677, L3678, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3981, L3982, L3984 and L3995

Diabetic Shoes: A complex review to determine if the item was reasonable and necessary. Affected codes A5500, A5501, A5512, A5513

KO: An automated review to determine if reasonable useful lifetime (RUL) requirements were met Affected codes: L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, L1860

AFO/KAFO:A complex review to determine that services were reasonable and necessary. Affected codes: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128.

KO: A complex review to determine if the item was reasonable and necessary. Affected codes: L1844 and L18466

KO: A complex review  of off-the-shelf KOs to determine if the item was reasonable and necessary. Affected codes: L1812, L1820, L1830, L1831, L1833, L1836, L1848, L1850, L1851,  and L1852

LSO/TLSO: A complex review to determine if Spinal Orthoses meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270.

LSO/TLSO: An automated review for Reasonable Useful Lifetime (RUL) limits. Affected Codes: L0627, L0631, L0637, L0642, L0648 and L0650

 Additional Documentation Requests: RAC Audit Limits for O&P

Additional Documentation Requests (ADRs)  for specific suppliers categorized under the following supplier taxonomy codes:

52—Medical Supply Company with Prosthetist
53—Medical Supply Company with Orthotist-Prosthetist
56—Individual Certified Prosthetist
57—Individual Certified Prosthetist-Orthotis
51—Medical Supply Company with Orthotist
55—Individual Certified Orthotist

Have a hard limit of no more than 10 ADR requests per 45 days.

More About the RAC Program

Visit the RAC Region 5 Contractor

To find the latest updates, visit CMS’ site about RAC Audits.

The Region 5 RAC statement of work may be found here.