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Medical Coding News Archives

CMS Updates Additional Documentation Limits At Provider Request

 
March 2, 2011:

The new limits, effective February 14, 2011, are as follows.

  • ADR limits will be based on the servicing providers’ billing tax identification number (TIN), as well as the first three positions of the ZIP code where that provider is physically located. For example, Group Medical has the TIN 123456789 and two physical locations in ZIP codes 12345 and 12356. This group would qualify as a single entity for additional documentation limit purposes.

However, Main Street Group Practice has TIN 123456780 and is physically located in 12345 as well as 21345. This group would qualify as two unique entities for ADR purposes, and each location would have its own ADR limits.

  • ADR limits are now based on the number of individual rendering providers reported under each TIN/ZIP combination in the previous calendar year. As the number of providers increase, so too will the number of ADRs a RAC can make. See the table below.

Number of ProvidersMaximum Number of Requests per 45 Days
50 or more50 records
25-4940 records
6-2425 records
Fewer than 510 records

For example, if a group practice has a total of 75 providers (physician and nonphysician practitioners), the RAC may request a total of 50 ADRs within the 45-day period. However, if a practice has only three providers, the RAC may make a request for only 10 ADRs within that same period.

It should be noted that CMS reserves the right to give a RAC permission to exceed the cap. Either the RAC or CMS may initiate the exceed request, and the affected physician or physician group will be notified in writing. CMS did not indicate the requirements for exceeding the cap requests.

Because it may be difficult for a RAC to accurately determine the size of a physician/practitioner group, there may be times when a request is made that does not adhere to the above guidelines. If such a request is received, the practice should contact the RAC with documentation of the group size. If the number of full-time equivalent physicians and nonphysician practitioners is significantly different from the number of individual rendering physicians and nonphysician practitioners appearing in the RAC’s claim data, the practice may request a modified limit. It is also recommended that practices work with the applicable RAC to establish a point of contact for the entire group and/or a single mailing address for RAC correspondence.

 

 
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