The Centers for Medicare & Medicaid Services (CMS) has posted a revised “Additional Documentation Limits for Durable Medical Equipment (DME) Suppliers,” effective April 4, which modifies the additional documentation request (ADR) limits for the Recovery Audit program in fiscal year (FY) 2013 for suppliers. These limits will be set by CMS on a regular basis to establish a cap per supplier on the maximum number of medical records that may be requested per Recovery Auditor (RA), per 45-day period. Each limit will be based on a given supplier’s prior calendar year Medicare claims volume within each Recovery Audit region.
- Limits will be based on the suppliers Tax Identification Number (TIN). A national supplier who has one TIN and has claims paid by all four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) will have claims available for review by all RAs.
- Limits will be set at 10 percent of all claims submitted for the previous full calendar year, divided into eight periods (45 days); in no case shall RAs make requests more frequently than every 45 days.
- The cap for FY 2013 will be 250 additional documentation requests per 45 days for all suppliers.
- Providers billing with provider specialty codes 51 (medical supply company with orthotist), 52 (medical supply company with prosthetist), 53 (medical supply company with orthotist-prosthetist), 55 (individual certified orthotist, 56 (individual certified prosthetist), or 57 (individual certified prosthetist-orthotist) will have an additional documentation limit not to exceed ten requests every 45 days. This limit will only be for O&P items or services on the claim. The standard durable medical equipment (DME) limits for these providers will apply for any other items or services.
- In 2013, in order to exceed the cap, RAs must request approval from CMS on a case-by-case basis; affected suppliers will be notified prior to receiving additional requests.
There is no minimum ADR limit for suppliers.
