Recovery Audit Contractor (RAC) Audits
On October 31, 2016 CMS announced the awarding of the new national contract for the Region 5 RAC (solely focused on claims for DMEPOS, Home Health, and Hospice) and the contract was awarded to Performant Recovery, Inc. (Performant Recovery was the RAC for Jurisdiction A.) The Region 5 RAC statement of work may be found here.
Current Items/Services Under a RAC Review as of 01/01/2020
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 Remain the Same
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.
Enhancements to the RAC Program under the new contract
View recent and future changes to the RAC program here.
More About the RAC Program
RAC Announcement on the Audit of L5845-Issue Has Been Removed from the RAC Website (5/01/2017)
In the April 20, 2017, AOPA announced that Performant Recovery, the contractor who serves as the national recovery audit contractor (RAC) for all Medicare DMEPOS, Hospice and Home Health services, had announced that it would begin performing an automated review on claims involving HCPCS code L5845 billed in conjunction with specific prosthetic knee codes.
AOPA reviewed the announcement on the Performant website and was immediately concerned that the RAC was not in compliance with its statement of work (SOW) which requires very specific criteria in order to implement an automated review. In a letter to the Performant Recovery Medical Director dated April 28, 2017, AOPA expressed its concern regarding Performant’s decision to initiate an automated review without meeting the specific criteria identified in its statement of work. View the letter.. The audit announcement for L5845 has been entirely removed from the “approved issues” section of the Performant Recovery website.