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CMS Outlines Claim History Data Use by Contractors

March 18, 2011:
The Centers for Medicare and Medicaid Services (CMS) has provided instructions to all contractors describing how claims history data should be used when examining Medicare claims during a medical review.

In general, Medicare contractors (affiliate contractors [ACs], Medicare administrative contractors [MACs], certified error rate testing contractors [CERT], and recovery audit contractors [RACs]) are NOT to use claims history information when determining claim payment. However, contractors are permitted to use claim history information for purposes such as determining duplication of services, overutilization and other data mining, and as a supplement to medical record information when performing complex reviews.

For example, CMS allows reviewers the discretion to use patient payment history to identify providers other than the billing provider who may have documentation to support payment of a claim and to contact those providers to request the additional supporting documentation.

Example: A diabetic beneficiary may have an order from a family practitioner but is also seeing an endocrinologist. The documentation from the family practitioner does not support the level of diabetic testing, but medical records from the endocrinologist do support the level of testing.

CMS also indicates that reviewers have the discretion to use claims history information to document an event, such as a surgical procedure, that supports the need for a service or item billed in limited circumstances. This event could be recent or could have occurred a number of years prior to the date of service on the claim being reviewed, making it difficult to collect medical record documentation. In these instances, claims history information can be used only to validate specific events; not as a substitute for the medical record.

Example: A beneficiary is eligible for immunosuppressant drugs only if she or he received an organ transplant. Patients generally remain on these life-saving drugs for the rest of their lives, so it is possible for a transplant to have occurred many years prior to the date of service being reviewed. If there was no record of the transplant in the medical documentation the ordering physician provided, the contractor may use claims history to validate that the transplant occurred.

According to the transmittal, reviews may also use claims history information to verify that the frequency or quantity of supplies provided to a beneficiary do not exceed policy guidelines or to determine the quantity of items to be covered based on policy guidelines. Information obtained on a claim being reviewed may be applied to a prior paid claim to determine how long the quantity of items provided/billed on the paid claim should last. If a new quantity of items is billed before the projected end date of the previously paid claim (based on policy guidelines), the new quantity should be denied.

Example: Twice-per-day testing of blood sugars is ordered for a noninsulin-treated beneficiary with diabetes. A three-month quantity of supplies (for twice-per-day testing) is provided on July 1 and is paid without review. Another three-month quantity of supplies is provided on 10/1. That claim is developed and reviewed and it is determined that the medically necessary frequency of testing is once per day. Therefore, the 10/1 claim should be denied because the quantity of supplies paid for on 7/1 was sufficient to last beyond 10/1 had testing been done once per day.

Deborah C. Hall
Clinical/Technical Editor


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