Program integrity at the Centers for Medicare & Medicaid Services (CMS) is under pressure to properly conduct Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) audits during the ongoing public health emergency (PHE).

Up high on the “to be audited” list is post-payment reviews of COVID-19 claims to confirm test results, since positive COVID tests can lead to 20-percent higher reimbursement rates. If a positive viral test result is not documented, the additional payment will be recouped in post-payment reviews. Remote patient monitoring (RPM) codes will also be targets for post-payment reviews, especially the RPM codes that include a defined time. For example, there’s CPT® 99458, which should be used to denote each additional 20 minutes of RPM.

However, do not expect resumed audits to include claims for dates of service (DOS) during the ongoing PHE…yet. As of now, CMS will only be reviewing claims submitted prior to March 1, 2020. While CMS has indicated that they do intend to audit claims submitted during the PHE, they do not plan to do so at this particular time. I would imagine, at a later date, claims during the pandemic will be scrutinized by CMS.

Another development in resumed RAC and MAC audits, post-August 2020, is the introduction of remote audits. These software programs have been created, but I am unaware of any test group results. I have high hopes for the veracity and efficiency remote audits may offer. Some pros are:

  • Auditors not physically on property, resulting in less disruption of consumer care;
  • Less burdensome on providers;
  • More organized, as computer files can be easily created to fit the providers’/auditors’ needs;
  • Digital tracking of all documents; and
  • Creates a digital record of the audit.

These remote audit software programs tout custom audit rooms, browse-only document binders, and micro-securitized content for regulatory teams. The remote audits allow for the current work-from-home, travel-restricted business climate. Interest in these tools has increased during the COVID-19 pandemic, as quality assurance (QA) and regulatory teams are now tasked with performing audits and compliance reviews remotely, since travel and onsite meetings have been largely restricted. 

COVID has pushed us to rely more on telehealth and RPM. This new, recently expanded acceptance of remote medical care and remote auditing can be helpful for both parties. Expect RPM claims to be high on auditors’ lists of services to audit.

Traditionally, audit fieldwork has involved a team of auditors camping out for weeks (or even months) in a conference room at the organization being audited. Thanks to technological advances – including cloud storage, smart devices, Zoom, and secure data-sharing platforms – audit firms have been gradually expanding their use of remote audit procedures.

Video conferencing and screen-share capabilities are also included within the solution, for many remote meetings. The Zoom-like features are available to all team members for instant collaboration.

Another hot topic in upcoming audits is coding for RPM. Note that per the April 30 inpatient final rule (IFR), CMS will allow remote physiologic monitoring services to be reported to Medicare for periods of time of fewer than 16 days, but no less than two days, during the PHE. For monitoring of less than 16 days, but more than two days, payment for CPT codes 99453, 99454, 99091, 99457 and 99458 is limited to patients who have a suspected or confirmed diagnosis of COVID-19.

Medical necessity will be critical for RPM. The justification for RPM should also be documented in the medical record in order to be compliant.

Programming Note: Knicole Emanuel, Esq. is a permanent panelist on Monitor Mondays. Listen to her RAC Report every Monday at 10 a.m. EST.

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