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Approved RAC Topics

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Issue Number - Name Review Type Claim Type Region and State 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 Health 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
0096-MSU Underpayments Automated Professional Services RAC 1-4
All States
2018-06-12
0097-MSU Overpayments Automated Professional Services 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 2018-10-09
0121-Consultation Services not covered under Part B Automated Outpatient Hospital RAC 1-4
All A/B MACs
12/11/2018
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
0125-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
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