Attention to Detail


Hospitalists will be essential players in helping their institutions prepare for the Recovery Audit Contractor (RAC) program, now being rolled out nationwide by the Centers for Medicare & Medicaid Services (CMS). The program is part of CMS’ arsenal to ferret out improper payments and prevent fraud, waste, and abuse in the Medicare system.

All providers who bill Medicare fee-for-service are fair game for an RAC audit, which scrutinizes medical records to validate diagnosis-related groups (DRGs), coding, and the necessity of care provided by hospitals. Hospitalists are being asked to document their diagnosis and treatment decisions more precisely and thoroughly than ever, ensuring that DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery.

Specificity of documentation is the hospitalist’s most potent weapon against this new layer of federal audits.

In a three-year demonstration of the RAC program that ended in March 2008, one-third of all medical records audited resulted in an overpayment finding and collection. RACs collected more than $900 million in overpayments and returned nearly $38 million in underpayments. One-third of provider appeals (physician, hospital, and other providers) were successful during the demo program, according to a June 2008 CMS evaluation report. (Download a copy of the report at

How the Audits Work

Coding rules and terminology often don’t match what we’re used to writing in the record. So hospitalists need to learn what these connections are and use them in their medical record documentation. This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.—Richard D. Pinson, MD, FACP, CCS, principal, HCQ Consulting, Nashville, Tenn.

Listen to an interview with Dr. Pinson

Out of concern that the Medicare Trust Fund might not be adequately protected against improper payments by existing error detection and prevention efforts, Congress directed CMS to use RACs to identify and recoup Medicare overpayments under Section 306 of the Medicare Modernization Act of 2003, and directed CMS to make the program permanent by 2010 under Section 302 of the Tax Relief and Health Care Act of 2006. According to CMS, RACs were implemented so that physicians and other providers could avoid submitting claims that do not comply with Medicare rules, CMS could lower its error rate, and taxpayers and future Medicare beneficiaries would be protected.1

CMS has contracted with four regional RACs for the national program, and each will use proprietary auditing software to review paid claims from Medicare Part A and Part B providers to ensure that they meet Medicare’s statutory, regulatory, and policy requirements and regulations.

The RACs use automated review for claims that clearly contain errors that resulted in improper payments (e.g., claims for duplicate or uncovered services, claims that violate a written Medicare policy or sanctioned coding guideline), in which case the RAC notifies the provider of the overpayment. For cases in which there is a high probability—but not certainty—that the claim contains an overpayment, the RAC requests medical records from the provider (including imaged medical records on CD or DVD) to conduct a complex review and make a determination as to whether payment of the claim was correct, or whether there was an over- or underpayment.

CMS uses a Web-based data warehouse to ensure that RACs do not review claims that have previously been reviewed by another entity, such as a Medicare carrier, fiscal intermediary, the Office of Inspector General, or a quality-improvement organization (QIO).

Connie Leonard

The four regional RACs are ramping up their claim review activities in all states, says Connie Leonard, director of CMS’ Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding providers to repay their Medicare carrier or intermediary within 30 days. For confirmed underpayments, RACs inform the provider’s Medicare contractor or fiscal intermediary, which then forwards the additional payment, Leonard says.

Providers can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. The Medicare contractors use recoupment—reducing present or future Medicare payments—on day 41. Providers who wish to dispute overpayment charges can take their case through the usual Medicare claims appeal process. RACs also offer a “discussion period”—from the date the provider gets a “Detailed Review Results” letter until the date of recoupment—to discuss with the RAC an improper payment determination outside the normal appeal process, Leonard says.

RACs are targeting confusion between septicemia and urosepsis.

—Kathy DeVault, RHIA, CCS, CCS-P, manager, Professional Practice Resources, American Health Information Management Association, Chicago

If providers disagree with the RAC’s determination, Leonard says, they should either 1) pay by check by day 30 and file for appeal by day 120 of the demand letter; 2) allow recoupment on day 41 and file for appeal by day 120; 3) stop the recoupment by filing an appeal by day 30; or 4) request an extended payment plan and appeal by day 120.

Some physicians in the demonstration project regarded the third-party RAC companies as “bounty hunters” operating without sufficient CMS oversight, imposing undue administrative burdens on physician practices, and lacking the clinical expertise to adjudicate claims appropriately, according to Michael Schweitz, MD, a rheumatologist from West Palm Beach, Fla., who testified before a Congressional committee in 2008 about RAC activities.

In response, CMS has modified the program (see “Refinements in Permanent RAC Program,” p. 8) in several ways to address those flaws and ensure a fair and smooth auditing process, Leonard says. (Listen to an audio interview with Ms. Leonard)

Key Things Hospitalists Should BEWARE Connie Leonard

Key Things Hospitalists Should BEWARE

Precise documentation is essential to ensuring DRG coding is appropriate, medical necessity is watertight, and hospitals are defended from costly overpayment recovery. The key is using the right clinical terminology that corresponds to the right codes, and being consistent throughout the record in your use of those terms. Document patient diagnoses, not just symptoms (e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina).

The RACs are targeting:

  • Incorrect coding for excisional debridement;
  • Confusion between septicemia and urosepsis;
  • Respiratory failure claims with incorrect sequencing of principal diagnosis, e.g., respiratory failure vs. sepsis;
  • Severity of patient's anemia failing to meet medical necessity for blood transfusion; and
  • Inadequate intensivist documentation for level of care provided in the ICU.—CG

All About the Details

Because RACs focus on coding and documentation that fails to support DRG designations, hospitalists who focus on accurate and precise documentation that can be coded properly will greatly help their hospitals defend against RAC audits, as well as yield better payment and improved quality scores, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Nashville, Tenn. Pinson will present “Documentation Tips Your Hospital Will Love You For” at HM10 in Washington, D.C., this month. A video/audio download of the presentation will be available on SHM’s Web site in May.

“Coding rules and terminology often don’t match what we’re used to writing in the record, so hospitalists need to learn what these connections are and use them in their medical record documentation,” Pinson says. “This is a core skill for hospitalists: being able to translate clinical terminology into the correct coding terminology for hospitals and coders.”

For example, if a hospitalist sees that a pre-operative patient has severe congestive heart failure, that condition cannot be coded as a complication of the patient’s care or considered as such in the DRG assignment, Pinson explains. If the hospitalist says the patient has an acute exacerbation of systolic heart failure, then that is a major comorbidity and ought to be documented as such. The average value of a major comorbidity in a surgical case could be as much as $20,000 per case, Pinson notes. If the DRG assignment included acute exacerbation but the medical chart only said severe congestive heart failure, the hospital would face recoupment of payment from an RAC audit.

“If we’re inconsistent or ambiguous in how we apply our terms, we can end up inadvertently upcoding. The key is: Learn to use the right terms that correspond to the right codes, based on what your patient actually has, and then be consistent throughout the record in your use of those terms,” Pinson says. For example, “we may admit a patient and say at the very beginning that the patient probably has aspiration pneumonia. We then treat the patient for aspiration pneumonia but leave it out of the discharge summary. The coder may code aspiration pneumonia, but the RAC auditor may point out that it was only mentioned in the patient’s record once, as possible, and may recoup any payment for treatment beyond simple pneumonia.”

Level of care and symptom-based DRG designations are red flags for RAC recovery, Pinson says. When the auditor sees a DRG based on symptoms rather than diagnoses (e.g., chest pain, syncope, transient ischemic attack, dehydration) and it is billed as inpatient status instead of observation status, that’s a target. Those symptoms, he says, often don’t meet the medical necessity criteria for inpatient status.

Pinson advises hospitalists to ask their institution’s case-management department, or hire an external consultant, to abstract key criteria for patient status designation, and to consider starting a patient as observation status until a precise diagnosis can be made that warrants hospital admission. Hospitalists should then describe the patient’s situation more precisely in the medical record as a diagnosis, not just as symptoms—e.g., syncope suspected due to cardiac arrhythmia, or chest pain suspected to be angina.

“For inpatient billing, those uncertain diagnoses, described that way, count as if they were established conditions. They don’t go into symptom DRGs,” Pinson says. “If you’re doing these things to protect the validity of you hospital’s billing, you’ll be protecting yourself at the same time, and it’s unlikely that RACs will single you out at all for auditing.”

Hospitalists can be valuable participants on their institutions’ RAC response team, providing clinical clarification on cases and helping to draft appeal letters.

There are several other red flags that RACs zero in on and hospitalists should watch out for, says Kathy DeVault, RHIA, CCS, CCS-P, manager of Professional Practice Resources for the American Health Information Management Association (AHIMA). Specificity in the medical record makes all the difference. For example, by identifying incorrect coding for excisional debridement (removal of infected tissue), RACs collected nearly $18 million in overpayments in fiscal-year 2006 because medical record documentation omitted such details as the word “excisional” (e.g., sharp debridement coded as excisional debridement), whether it was performed in the operating room or not, instruments used, the extent and depth of the procedure, and if the cutting of tissue was outside or beyond the wound margin.

DeVault warns that “RACs are targeting confusion between septicemia and urosepsis.” According to CMS, if the hospital reports a patient’s principal diagnosis as septicemia (03.89) but the medical record indicates the diagnosis of urosepsis, the RAC will bump the diagnosis code down to urinary tract infection (599.0), a lower-payment DRG, and demand recoupment.1

Urosepsis does not have a specific ICD-9-CM diagnosis code, and defaults to a simple UTI code, as referenced in ICD-9-CM. Unless the physician states in his or her documentation that the patient’s condition was systemic sepsis or septicemia, urosepsis would be coded as a UTI. RACS also denied some respiratory-failure claims for incorrect sequencing of principal diagnosis (e.g., respiratory failure vs. sepsis). The American Hospital Association has issued a regulatory advisory about these issues ( Advisory_071608.pdf).

DeVault highlights three additional RAC targets that might impact HM:

  • Documentation for transbronchial biopsy (a surgical DRG) in which the medical record only shows pathology of bronchus tissue (which RACs regard as nonsurgical);
  • Failure to document the severity of a patient’s anemia as such to meet the medical necessity requirement of a blood transfusion (e.g., a chronic blood loss anemia or a pernicious anemia); and
  • Documentation of treatments performed by intensivists in an ICU. By the time a patient’s attending physician sees their patient out of the ICU, DeVault says, their acute renal failure could be turned around but the attending might not document what happened in the ICU. The intensivist must see to it that the documentation allows the appropriate DRG assignment for the level of care the patient received.

AHIMA has published a 65-page RAC Audit Toolkit that describes the audit process, outlines preparations and procedures, and offers concrete guidance for appeals. Download a copy at TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.


  1. The Medicare Recovery Audit Contractor (RAC) program: an evaluation of the 3-year demonstration. CMS Web site. Available at: Accessed March 3, 2010.

Refinements in CMS’ Permanent RAC Program

Key Things Hospitalists Should BEWARE Connie Leonard

Based on lessons learned from demonstration programs, CMS has made a number of changes to the permanent Recovery Audit Contractor (RAC) program.

Among the changes are:

  • RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
  • For physicians, RACs are limited to requesting 10 medical records per 45 days from a single physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15, and 50 from a large group of more than 16 physicians;
  • For hospitals, RACs are limited to requesting 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days;
  • RACs must send a “Detailed Review Results” letter within 60 calendar days of receipt of the medical records they request for review;
  • Each RAC must hire a physician medical director and certified coders, and providers may request the credentials of their auditor and request to speak to their RAC’s medical director regarding a claim denial;
  • All new issues that an RAC wishes to pursue for overpayments must be validated by CMS or an independent RAC validation contractor, and posted to the RAC’s Web site before widespread review;
  • RACS must have a Web-based “Claim Status” platform that will allow providers to track the status of medical record submissions to RACs;
  • RACs must pay back contingency fees when an improper payment determination is overturned at any level in the appeals process (demo RACs were allowed to retain them on determinations overturned on second- and third-level appeal); and
  • RAC validation contractors will conduct a third-party review of RAC claims determinations and provide annual accuracy scores for each RAC.—CG

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