Tuesday, April 14, 2015

CMS Manual Changes Allow Auditors to Adjust Claims Up/Down

Dianne De La Mare

CMS has just released Pub 100-08 Medicare Program Integrity, Transmittal 585, that allows Medicare Administration Contractors (MACs), Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing (CERT) contractor, Zone Program Integrity Contractors (ZPICs) and Recovery Auditors to refrain from denying the entire claim when the medical record supports a higher or lower level code and instead just adjust the code and the payment. In the past, these claims would just be denied but now they will be adjusted according to what the reviewer believes is appropriate.

To obtain the new guidance go to http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R585PI.pdf

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