Each RAC annually is expected to establish a per-campus cap on the maximum number of medical records it can request per 45-day period. A campus unit may consist of one or more separate facilities or practices operating under a single organizational umbrella; each limit will be based on units’ Medicare claims volume for the prior calendar year.


Determining Limits

Limits will be based on the provider’s or supplier’s Tax Identification Number (TIN) and the first three positions of the ZIP code of their physical location. According to CMS, using TINs will reduce the total number of limits that would have been imposed per organization under the previous draft policy (which was based on national provider identifiers). Factoring in ZIP codes will promote equitability for regional and national organizations.


For example, if provider A has TIN No, 123456789 and two physical locations in ZIP codes 12345 and 12356, the two sites would qualify as a single campus unit.


If provider B has TIN No. 123456780 and two physical locations in ZIP codes 12345 and 21345, this provider would be considered two distinct entities and each location would have its own documentation limit.


Setting Limits

Limits will be set at 1 percent of all claims submitted during the previous calendar year (2008), divided into eight periods (45 days). Although the RACs may go beyond 45 days between requests, they will never make requests more frequently than this. A limit will be applied across all claim types, including professional services. Note: FY 2010 limits are based on submitted claims, irrespective of paid or denied status and/or individual lines, although interim/final bills and final claims shall be considered as individual units.


For example, if provider C billed 156,253 claims, the additional documentation limit would be (156,253 X .01) / 8 = 195.31, or 195 ADRs per 45 days.


While respecting a provider’s overall limit, RACs may exercise discretion in the exact composition of an additional documentation request. For example, the RAC may request inpatient records up to the full limit even though the provider’s inpatient business may represent only a small portion of its total claim volume.


Two Caps Set


The cap will remain at 200 ADRs per 45 days through March for all providers and suppliers. From April through September, those that bill more than 100,000 claims to Medicare will have a cap of 300 ADRs per campus unit, per 45 days.


Exceeding the Cap

In FY 2010 CMS will allow RACs to request permission to exceed the cap, but not during the first six months of the FY. The RACs must request approval from CMS on a case-by-case basis and affected providers will be notified before receiving additional requests.


The above information, current as of Jan. 28, is available at http://www.cms.hhs.gov/RAC/Downloads/DRGvalidationADRlimitforFY2010.pdf, is


About the Author

Barbara Vandergrift, RN, BSN, MA, is a senior healthcare consultant with Medical Learning, Inc. (MedLearn), St. Paul, MN. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that will equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.

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