Medicaid RAC audit issue resolved

Medicaid RAC audit issue resolved


Updated May 8, 2024

In a May 1, 2024 communication, HCPF officially confirmed the fix to the initial hospital care code audit: “We have halted mailing on this audit and will ensure that no other notices are mailed for medical claims billed before 2023. Overpayments will only be identified for claims billed in 2023 when a physician from the same specialty and subspecialty who belongs to the same group practice billed the initial hospital care code (99221-99223) for the same patient during the same inpatient admission. This same criteria will be applied to all existing informal reconsideration requests and appeals identified through this audit. Going forward, we will use the E&M medical coding that was in place at the time the claim was billed, which is the normal process for any RAC audits.”          

While it has taken longer than expected, the Colorado Medical Society is pleased to receive this official confirmation. We are grateful for and encourage physicians across the state to continue to care for Medicaid patients. CMS appreciates HCPF’s work on this issue.


Original story: Feb. 8, 2024

On Jan. 30, Colorado Medical Society (CMS), Colorado Hospital Association (CHA), and the Department of Health Care Policy and Financing (HCPF) resolved outstanding concerns related to Medicaid audits regarding “Excessively Billed Evaluation and Management Initial Hospital Care Codes” (i.e., inpatient specialty audit).  

Since November 2022, there has been a coding disagreement regarding Health First Colorado billing audits for certain codes used when a physician sees a patient in the hospital for the first time and provides care that includes higher levels of medical decision-making. Specifically, the disagreement was about whether admitting providers and other specialty physicians can bill for the initial visit the first time they see the patient for any given hospital stay. HCPF will recognize that providers who are evaluating a patient for the first time can bill the initial hospital care code (codes 99221 to 99223) and has agreed to update the RAC audit to reflect these guidelines. Additional background on the audit can be found here.  

HCPF will reprogram the audit to exclude these codes moving forward. Also, it will resolve all existing cases flagged as part of this coding sequence that are in informal reconsideration and appeal. HCPF plans to release formal guidance at the end of February 2024 for how to resolve these claims. The other aspects of the audit will continue. For example, if two providers of the same specialty see the same patient for the same condition and improperly bill the same initial hospital care code, that will continue to be flagged as a violation of Medicaid and AMA coding policies.