CQW Panacea-re-brand-rev3


For the Week of April 27, 2015


If only one portion of a claim has been incorrectly billed, why must Medicare contractors deny the entire claim?


The Centers for Medicare & Medicaid Services (CMS) recently issued a new policy about this. Specifically, when the medical record supports a higher or lower level code, Medicare administrative contractors (MACs) (and several other contractors including recovery auditors) shall not deny the entire claim but instead shall adjust the code and adjust the payment.

In transmittal R585PI (issued April 3 and effective May 4, 2015), CMS states that contractors may up-code or down-code claim entries when it is possible to pay for the item or service actually provided without making a reasonable and necessary determination or if otherwise specified in applicable medical-review instructions.

More on this directive can be found at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R585PI.pdf.

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