Limits Now Apply to All Institutional Claim Types, Not Just DRG Validations
The Centers for Medicare & Medicaid Services (CMS) modified its FY2010 Additional Documentation Request (ADR) Limits, expanding the scope of the rule to include all institutional providers, on January 28, 2010. Previously, the rule applied to ADRs for DRG Validation issues only, as posted by CMS on December 1, 2009, and would have only applied to Medicare Part A providers. CMS also indicated that more changes are yet to come, with rules applying to physicians and other types of providers, including DME suppliers.
The December posting indicated that there would be two “caps” made on RAC ADRs, during FY2010. Through March 2010, the cap would remain at 200 ADRs per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 claims to Medicare, across all claims processing contractors, would have a cap of 300 ADRs per per 45 days.
These limits would apply per “campus” instead of per NPI (National Provider Identifier). The definition of a campus is CMS’s new method of calculating limits, and is based on providers’ Tax ID Numbers plus the first three numbers of the ZIP code where those provider entities are physically located.
This most recent posting does not change any of the previous limits or definitions, but does expand the rule to apply to all claim types, not just DRG Validations.
Read the new document HERE , along with a copy of the text from the December document.
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