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CMS OKs 'Medical Necessity' Reviews for RAC

James Carroll, for HealthLeaders Media, August 12, 2010

"This will be an interesting twist to the current set of approved issues, which are more 'cut and dry'," said Mackaman.

The newly approved audits include 18 types of inpatient hospital claims and one durable medical equipment claim. It is unclear as to which RACs will post which issues to their websites, as required by CMS. According to the AHA, these issues, as well as the accompanying additional documentation requests (ADR), are expected to be released within the next two weeks.

When providers receive these ADRs, they should take the time to carefully review all documentation well in advance of receiving the review results letter, suggests Mackaman.

"The review should involve clinical staff and CDI specialists, as well as a physician advisor in preparation for a denial and possible appeal," she says. "Knowing where you stand and being prepared to take on the denial will save critical time as these issues continue to unfold."

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