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Approved RAC Topics

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Issue Number - Name Review Type Provider Type RAC Region/MAC Jurisdiction Date Approved
0001 - Inpatient Hospital MS - DRG Coding Validation Complex Inpatient Hospital RAC 1-4
All States
2017-02-01
0002 - Cataract Removal- Reasonable and Necessary Requirements and Coding Requirements Complex Outpatient Hospital, Ambulatory Surgical Center RAC 1-4
All States
2017-02-01
0003 - Sacral Neurostimulation- Reasonable and Necessary Requirements and Coding Requirements Complex Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Physician /Professional Services RAC 1-4
All States
2017-02-01
0004 - Medical Necessity and Coding SNF Review Complex SNF RAC 1-4
All States
2017-02-01
0047 - Panretinal (Scatter) Laser Photocoagulation - Excess Frequency Automated Outpatient Hospital (OPH) and Physician/ Non-physician Practitioner J6, JK, J15 2017-02-23
0049 - Ambulance SNF to SNF Transfer Automated Ambulance Providers RAC 1-4
All States
2017-08-08
0008 - Bariatric Surgery Complex Outpatient Hospital RAC 1-4
All States
2017-02-01
0050 - Add-on Codes Paid without Primary Code and/or Denied Primary Code Automated Physician, Professional Services/Outpatient Hospital Services RAC 1-4
All States
2017-04-11
0010 - Cardiac PET Scans Complex Outpatient Hospital, Physician/Professional Services RAC 3
JN, First Coast only
2017-02-01
0051 - Automated Global vs.TC/PC Split Reimbursements Automated Outpatient Hospital, Physician/Non-physician Practitioner RAC 1-4
All States
2017-04-18
0011 - Inappropriate Billing of Home Visit Professional Service E&M Codes during Inpatient Automated Professional Services (Physician/ non Physician Practitioner RAC 1-4
All States
2017-02-01
0054 - Ambulance Billed During Inpatient Stay Automated Ambulance Providers RAC 1-4
All States
2017-05-19
0012 - Complex Blood Glucose Monitors with Integrated Voice Synthesizer Billed Without Indicator of Medical Necessity Complex DME Supplier RAC 5
All States
2017-05-08
0056 - Evaluation and Management (E/M) Coding in Skilled Nursing Facilities Automated All physician/NPP specialties RAC 1-4
All States
2017-08-01
0013 - Complex Comprehensive Medical Necessity AFO & KAFO Orthoses Complex DME by Supplier RAC 5
All States
2017-07-05
0014 - Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling) Complex DME by Supplier, DME by Physician RAC 5
All States
2017-02-01
0015 - Enteral Nutrition Therapy Complex DME Supplier RAC 5
All States
2017-05-08
0057 - Arthroscopic Limited Shoulder Debridement Complex Outpatient Hospital (OPH), Ambulatory Surgery Center (ASC), Physician/Non- Physician Practitioner (NPP) RAC 1-4
All States
2017-09-06
0093 - Automatic Defibrillators Complex Professional Services (Physician/Non-Physician, Outpatient Hospital, Ambulatory Surgery Center) RAC 1-4
All States
2018-05-08
0060 - Excessive Units - Untimed Therapy Automated Outpatient Hospital, Part B Professional Services, Outpatient Non-Hospital Facility, Skilled Nursing Facility (SNF), Outpatient Rehab Facility (ORF), Comprehensive Outpatient Rehab Facility (CORF), Physician and Non-Physician Practitioner/ Provider Specialty, RAC 1-4
All States
2017-09-06
0061 - Excessive Units of Nursing Facility Services Automated Professional (Physician/Non-Physician Practitioner) RAC 1-4
All States
2017-09-06
0016 - CPM Billed Without Total Knee Replacement Automated DME Supplier RAC 5
All States
2017-02-01
0017 - Negative Pressure Wound Therapy Complex DME Supplier RAC 5
All States
2017-04-26
0062 - TC of Radiology Inpatient - FULL Automated Radiologists and other Part B providers performing radiology services RAC 1-4
All States
2017-09-06
0018 - Spring Powered Devices Billed for More Than 1 Unit in a 6-Month Period- Excessive Units of Spring Powered Devices Automated DME by Supplier RAC 5
All States
2017-02-01
0063 - Excessive Units of Initial Critical Care Automated Professional Services (Physician/Non-Physician Practitioner) RAC 1-4
All States
2017-09-06
0064 - Facility Duplicate Claims Automated Hospital Facility, Skilled Nursing Facility (SNF), Clinics, Outpatient Rehabilitation Facility (ORF), Comprehensive Outpatient Rehabilitation Facility (CORF) RAC 1-4
All States
2017-09-06
0019 - DME Billed While Inpatient Automated DME Supplier RAC 5
All States
2017-02-01
0091 - Exact Duplicate Claims Automated Professional Services (Physician/Non-Physician, Outpatient Hospital) RAC 1-4
All States
2018-05-08
0020 - Complex Medical Necessity Patient Lifts Complex DME by Supplier and DME by Physician RAC 5
All States
0021 - Trach Suction Catheters Complex DME by Supplier, DME by Physician RAC 5
All States
2017-02-01
0070 - Critical Care billed on the same day as Emergency Room Automated Physician/Non-Physician Practitioner RAC 1-4
All States
2017-10-04
0071 - Initial Hydration, Infusion and Chemotherapy Administration Automated Professional Services (Physician/Non-Physician Practitioner) RAC 1-4
All States
2017-10-05
0022 - Inpatient Psych Automated Inpatient Hospital, Inpatient Psychiatric Facility RAC 1-4
All States
2017-02-01
0023 - Chest Wall Oscillation Devices Complex DME by Supplier, DME by Physician RAC 5
All States
2017-02-01
0072 - Outpatient Service Overlapping or During an Inpatient Stay Automated Hospital Outpatient, Hospital Inpatient Part B RAC 1-4
All States
2017-10-05
0024 - Complex Comprehensive Spinal Orthosis Delivery Complex DME by supplier, DME by physician RAC 5
All States
2017-08-02
0074 - Excessive or Insufficient Drugs and Biologicals Units Billed Complex Outpatient Hospital Claims & Physician Claims RAC 1-4
All States
2017-12-21
0076 - Evaluation and Management (E/M) Same Day as Dialysis Automated All Physician/NPP specialties RAC 1-4
All States
2018-01-09
0077 - Annual Wellness Visit (AWV) Billed Sooner Than 11 Whole Months Following the Initial Preventative Physical Examination (IPPE) Automated Physician/Non-Physician Practitioner RAC 1-4
All States
2018-01-09
0078 - Complex Cardiac Pacemaker Review Complex Outpatient, Ambulatory Surgery Center RAC 1-4
All States
2017-12-12
0025 - Nebulizers Billed With Diagnosis Codes Other Than Those Listed in Local Coverage Determination Automated DME Supplier RAC 5
All States
2017-02-01
0079 - Ventilators Subject to DWO Requirements on or after January 1, 2016 Complex DME by supplier; DME by physician RAC 5
All States
2017-12-12
0080 - Group 2 Support Surfaces - DWO Complex DME by supplier; DME by physician RAC 5
All States
2018-02-26
0081 - Complex Medical Necessity Negative Pressure Wound Therapy (NPWT) with DWO Complex DME by supplier; DME by physician RAC 5
All States
2018-02-13
0082 - Ventilators Subject to ACA Requirements Complex DME by supplier; DME by physician RAC 5
All States
2018-02-13
0083 - Cataract Removal Excessive Units (Partial) Automated Professional Services (Physician/Non-Physician ; Outpatient Hospital RAC 1-4
All States
2018-02-13
0026 - Nebulizers- Medical Necessity Complex DME by Supplier and DME by Provider RAC 5
All States
2017-04-11
0084 - Cataract Removal Excessive Units (Full) Automated Professional Services (Physician/Non-Physician; Outpatient Hospital; Ambulatory Surgery Center) RAC 1-4
All States
2018-02-13
0085 - Lab Services Rendered During an Inpatient Stay Automated Lab/Ambulance RAC 1-4
All States
2018-02-13
0086 - Observation Evaluation & Management (E&M) codes billed Same Day as Inpatient Admission Automated Professional Services (Physician/Non-Physician; Outpatient Hospital) RAC 1-4
All States
2018-02-13
0027 - Improper Payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Services Complex Outpatient Hospital (OPH), Physician RAC 1-4
All States
2017-03-24
0087 - Labs Subject to Part B Consolidated Billing - ESRD Automated Professional Services (Physician/Non-Physician; Outpatient Hospital) RAC 1-4
All States
2018-02-13
0088 - Ancillary Services Billed Without an Approved Surgical Procedure Automated Ambulatory Surgery Center RAC 1-4
All States
2018-02-13
0089 - Clinical Social Worker during Inpatient Automated Clinical Social Worker RAC 1-4
All States
2018-02-13
0090 - TC of Lab/Pathology for Outpatient Hospitals Automated Professional Services (Physician/Non-Physician) RAC 1-4
All States
2018-02-13
0028 - Annual Wellness Visits (AWV) Automated Physician/ Non-physician Practitioner RAC 1-4
All States
2017-03-29
0075 - Complex Home Health Review: Documentation and Medical Necessity Complex Home Health RAC 5
All HHA MACs (except for the demonstration states: Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia)
2017-12-12
0069 - Respiratory Assist Device Automated DME by supplier; DME by physician RAC 5
All States
2017-12-12
0029 - Group 2 Support Surfaces Complex DME by Supplier, DME by Physician RAC 5
All States
2017-07-10
0066 - Complex PAP Devices for the Treatment of Obstructive Sleep Apnea Complex DME Supplier, DME by Physician RAC 5
All States
2017-09-07
0065 - DME CPAP without Obstructive Sleep Apnea Diagnosis Automated DME Supplier, DME by Physician RAC 5
All States
2017-09-07
0030 - Osteogenesis Stimulators - Medical Necessity Complex DME by Supplier, DME by Physician RAC 5
All States
2017-02-01
0053 - Group 3 Power Wheelchair Options Underpayments Automated DME Supplier and DME by Physician RAC 5
All States
2017-05-17
0094 - Group 3 Support Surfaces Complex DME by supplier, DME by physician RAC 5
All States
2018-05-08
0046 - Multiple DME Rentals in One Month Automated DME by Supplier and DME by Physician RAC 5
All States
2017-03-29
0031 - Power Mobility Devices Not Subject to PA Demonstration Complex DME by Supplier and DME by Physician RAC 5
All States
2017-06-06
0032 - E&M Codes billed within a Procedure Code with a 0 Day Global Period (Endoscopies or some minor surgical procedures) Automated Professional Services (Physician/Non-Physician Practitioner) RAC 1-4
All States
2017-12-12
0033 - E&M Codes billed within a Procedure Code with a 10 Day Global Period (other minor procedures) Automated Professional Services (Physician/Non-Physician Practitioner) RAC 1-4
All States
2017-12-12
0034 - E&M Codes billed within a Procedure Code with a 90 Day Global Period (major surgeries) Automated Physician/Non-Physician Practitioner RACS 1-4
All States
2017-12-12
0036 - Trastuzumab (Herceptin), Multi-Dose Vial Complex Physician, Outpatient Hospital, Professional Services (Physician/Non-Physician Practitioner) RAC 1-4
All States
2017-02-01
0037 - Excessive Units of Hospital Services Automated Professional Services (Physician/Non-physician Practitioner) RAC 1-4
All States
2017-02-23
0038 - Visits to Patients in Swing Beds Automated Physician, Professional Services RAC 1-4
All States
2017-02-23
0039 - Not a New Patient – Ophthalmology Codes Automated Physician, Professional Services RAC 1-4
All States
2017-03-09
0040 - Hospital Discharge Day Management Service Automated Physician, Professional Services RAC 1-4
All States
2017-03-09
0042- Office Visits Billed for Hospital Inpatients Automated Professional Services (Physician/Non-Physician Practitioner) RAC 1-4
All States
2017-03-09
0043 - New Patient Visits Automated Physician/Non-physician Practioner RAC 1-4
All States
2017-03-09
0092 - Percutaneous Implantation of Neurostimulator Electrode Array Complex Professional Services (Physician/Non-Physician, Outpatient Hospital, Ambulatory Surgery Center) RAC 1-4
All States
2018-05-08
0095-Facet Injections Complex Outpatient Hospital, Ambulatory Surgery Center RAC 1-4
All States
2018-06-12
0098-Unbundling of Critical Care Automated Professional Services Rac 1-4
All States
2018-06-12
0099-Skilled Nursing Facility (SNF) Consolidated Billing Automated Outpatient Facility RAC 1-4
All States
2018-06-12
0100-Add-on codes paid without Primary Code and/or denied Primary Code-by Clinical Laboratory Automated Laboratory RAC 1-4
All States
2018-06-12
0101-Outpatient Hospital Comprehensive APC Coding Complex Outpatient Hospital RAC 1-4
All States
2018-07-10
0102-Home Oxygen Complex DME by Supplier; DME by Physician Region 5
All States
2018-07-10
0103-Complex Urological Supplies Complex DME by Supplier, DME by Physician RAC 5
All States
2018-07-10
0104-Add-ons paid without a Primary and/or Denied code by ASC Automated A0mbulatory Surgical Center (ASC) RAC 1-4
All States
2018-07-10
0105-Physician Services during Hospice Period Automated Physician/Non-Physician Practitioner RAC 1-4
All States
07/10/2018
0073-Inpatient Rehabilitation Facility (IRF) Stays:Meeting Requirements to be considered Reasonable and Necessary Complex IRF RACS 1-4
All States
09/11/2018
0106-Parenteral Nutrition-Medical Necessity Complex DME by Supplier; DME by Physician RAC 5
All States
09/11/2018
0107-Custom Fabricated Knee Orthoses:Medical Necessity Complex DME by Supplier, DME by Physician RAC 5
All States
09/11/2018
0111-Transthoracic Echocardiography Complex Inpatient Hospital, Outpatient Hospital, SNF, CAH CGS, First Coast, NGS, Palmetto 2018-09-11
0113-Radiologic Examination of the Chest Automated Physician/Non-Physician Practitioner Noridian (JE, JF) 09/11/2018
0108-Facility vs. Non-Facility Reimbursement Automated Physician/Non-Physician Practitioner RAC 1-4
All States
09/11/2018
0114-DME while in Hospice Automated DME by Physician, DME by Supplier RAC 5
All States
09/11/2018
0109-Skilled Nursing Facility (SNF) Consolidated Billing Part B (Full) Automated Physician/Non-Physician Services RAC 1-4
All States
09/11/2018
0110-Skilled Nursing Facility (SNF) Consolidated Billing Part B (Partial) Automated Physician/Non-Physician Practitioner RACS 1-4
All States
2018-09-11
0112-MCP (Monthly Capitation Payment) for ESRD (End Stage Renal Disease) receiving 4 or more visits per month Automated Physician/Non-Physician Practitioner RAC 1-4
All States
09/11/2018
0116-Improperly Paid Modifiers TC and 26 Automated Professional Services (Physician/Non-Physician Practitioner RACs 1-4
All A/B MACs
2018-10-09
0118-Arthroscopic Extensive Shoulder Debridement Automated Professional Services (Physician/Non-Physician Practitioner) All A/B MACs 2018-10-09
0117-Automated Arthroscopic Shoulder Limited Debridement Automated Professional Services (Physician/Non-Physician Practitioner) RACs 1-4
All A/B MACs
2018-10-09
0115-Home Visits Physician Services Overlapping Inpatient Stay Automated Physician RACs 1-4
All MACs
2018-10-09
0124-Part B Therapies in a Hospital Setting Automated Physical Therapist, Occupational Therapist, Speech Therapist RAC 1-4
All MACs
12/11/2018
0119-Transforaminal Epidural Steroid Injection to the Lumbar or Sacral Level Complex Professional Services (Physician/Non-Physician Practitioner) JE, JF, JL and JH 2018-10-09
0122-Outpatient Hospice-Related Services Automated Part A Inpatient RAC 1-4
All A/B MACs
12/11/2018
0123-Techincal Component (TC) of Diagnostic Procedures during an Inpatient Stay Automated Physician/Non-Physician Practitioner, Independent Diagnostic Testing Facility (IDTF) RAC 1-4
All A/B MACs
12/11/2018
0121-Excessive Units of Destruction of Premailignant Lesions Automated Physician/Non-Physician Practitioner RAC 1-4
All A/B MACs
12/11/2018
0126-Endoscopy Procedures Diagnostic and Surgical Same Day Automated Outpatient Faciltiy, ASC, Professional Services RAC 1-4
All A/B MACs
12/11/2018
0127-Transforaminal Epidural Injections Bill with Guidance Automated Physician/Non-Physician Practitioner RAC 1-4
All A/B MACs
12/11/2018
0128-Spinal Orthoses within the Reasonable Useful Lifetime (RUL) Automated DME by Supplier, DME by Physician RAC 5
All DME
12/11/2018
0130-Medical Neccesity Pannulectomy Complex Outpatient Hospital, Ambulatory Surgical Center, Physician/Non-Phsycian Services RAC 1-4
All A/B MACs
1/08/2019
0131-Pneumatic Compression Device Complex DME by supplier, DME by Physician RAC 5
DME A,B,C,D
2019-01-08
0132-Evaluation and Management (E&M) Same Day as Admission to a Nursing Facility Automated Physician/Non-Physician Practitioner RAC 1-4
All A/B MACs
2019-01-08
0133-PET Scans Paid without Tracer Codes for IDTF (Independent Diagnostic Testing Facility) Providers Automated Indpendent Diagnostic Testing Facility RAC 1-4
All AB MACs
2019-01-08
0134-Cryosurgery of the Prostate Complex Outpatient Hospital, Ambulatory Surgical Center (ASC), Physician/Non-physician Practitioner RAC 1-4
All A/B MACs
2019-01-08
0136-Medical Necessity and Coding of Chest X-rays Complex Outpatient Hospital RAC 1-4 2019-01-08
0137-IV Hydration Administration Complex Outpatient Hospital JE 2019-01-08
0135-Cardiac Rehabilitation Complex Outpatient Hospital RAC 1-4
All A/B MACs
2019-01-08
0139-Complex Medical Necessity Vertebroplasty and Kyphoplasty (Vertebral Augmentation) Complex Outpatient Hospital (OPH), Ambulatory Surgery Center (ASC), Physician/Non-physician Practitioner (NPP) RAC 1-4
All A/B MACs
02/12/2019
0138-SNF-Consolidated Billing for Therapies Automated Physician/Non-physician Practitioner, Physical Therapist, Occupational Therapist, Speech-Language Pathologist RAC 1-4
All States
02/12/2019
0125-Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth) Automated Professional Services (Physician/Non-physician Practitioners RAC 1-4
All States
02/12/2019
0145-Endovenous Radiofrequency Ablation (ERFA) and Endovenous Laser Treatment (EVLT) for Lower Extremity Varicose Veins Complex Ambulatory Surgical Center, Outpatient Hospital, Professional Services First Coast, NGS, Novitas, Palmetto, WPS, CGS, Noridian 02/05/2019
0146-Unbundling of CT Scans Automated Outpatient Hospital, Professional Services RAC 1-4
All States
02/05/2019
0140-Pulmonary Rehabilitation Complex Outpatient Hospital RAC 1-4
All States
02/05/2019
0147-Unbundling of MRI Procedures Automated Professional Services, Outpatient Hospital RAC 1-4
All States
02/05/2019
0141-Therapeutic Shoes and Inserts for Persons with Diabetes Complex DME by Supplier, DME by Physician A,B,C,D 02/05/2019
0142-ASC Services During a Covered Part A SNF Stay Automated Ambulatory Surgical Center (ASC), Skilled Nursing Facility (SNF) RAC 1-4
All States
02/05/2019
0143-Medical Necessity for Vitamin Assay D Testing (CPT 82306, CPT 82652) Complex Laboratory Services JE/JF 02/05/2019
0144-Off-the-Shelf-Knee Orthosis Complex DME by Supplier, DME by Physician RAC 5
All DME
02/05/2019
0148-Knee Orthosis within the RUL Automated DME by Supplier, DME by Physician RAC 5
All DME MACs
03/05/2019
0149-Subsequent Hospital Visit and Discharge Day Management Billed on Same Day Automated Professional Services RAC 1-4
All Regions
03/05/2019
0150-Mohs Micrographic Surgery (MMS)-Incorrect Units Billed Complex Professional Services RAC 1-4
All Regions
03/05/2019
0151-Physician/Non-physician Practitioner Coding Validation Complex Professional Services RAC 1-4
All Regions
03/05/2019
0152-HCPCS A4253: Blood Glucose Tes or Reagent Strips Complex DME by Supplier, DME by Physician RAC 5
All DME MACs
03/05/2019