Will RACs review claims for evaluation and management services?

Yes, but the AAFP along with the AMA and multiple other medical specialties have sent a formal request to Medicare asking that this not include the level of service reported, due to the complexity of interpreting physician documentation to support the codes reported.

The Centers for Medicare and Medicaid Services (CMS) has stated, “The review of duplicate claims or [evaluation and management] E/M services that should be included in a global surgery were available for review during the RAC demonstration and will continue to be available for review. The review of the level of the visit of some E/M services was not included in the RAC demonstration. CMS will work closely with the American Medical Association and the physician community prior to any reviews being completed regarding the level of the visit and will provide notice to the physician community before the RACs are allowed to begin reviews of evaluation and management (E/M) services and the level of the visit.”

One evaluation and management (E/M) services issue has been approved for review in Region D, where Health Data Insights is the RAC. This review entails a review of claims data to find new patient visit codes reported by the same physician or a physician of the same specialty within a group practice for patients who have previous claims for visits to the physician or practice within the prior three years.

This issue should not affect physicians who follow CPT and Medicare guidance regarding the selection of new and established patient E/M codes. Interpret “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (for example, surgical procedure), from the physician or another physician of the same specialty in the group within the previous three years. Note that interpreting a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service does not affect the designation of a new patient. If a professional component of a procedure is billed but no E/M service or other face-to-face service with the patient has been performed in three years, then the patient remains a new patient for the initial visit.