Recovery Audit Contractor Overpayments: Pulmonary Diagnostic Testing and E/M Services

The Medicare Modernization Act of 2003 established the Medicare Recovery Audit Contractor (RAC) program to identify fraud and waste in the Medicare system.

The California Medical Association (CMA) has recently learned that RAC contractor Health Data Institute (HDI) is currently assessing overpayments for evaluation and management services billed without a modifier -25 on the same day as a diagnostic pulmonary study. Affected claims have dates of service of 2009 or 2010.

In order for a physician to receive payment for a E/M visit on the same day as a service in the pulmonary diagnostic range (i.e., any service in the series from 94010 to 94620), the physician must append a modifier -25 with the visit code, indicating that the patient's condition required a significant, separately identifiable visit above and beyond the diagnostic service provided. For additional information, please refer to The National Correct Coding Initiative Policy Manual (http://cal.md/ncci-manual). See Chapter 11, Evaluation and Management Services, Codes 90000 to 99999, Section J. Pulmonary Services.

Physicians should appeal the overpayment if medical record documentation supports the E/M code. Submit the medical record and request that the modifier -25 be appended to the E/M code. Redetermination request forms for RAC overpayments are available at http://cal.md/rac-redetermination.

Comments are closed.