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Medical Coding News Archives

CMS Proposes Giving Contractors More Control Over Medical Reviews

July 27, 2012:

Deborah C. Hall, Clinical/Technical Editor

The Centers for Medicare and Medicaid Services (CMS) has proposed giving contractors more discretion in deciding when to take providers and suppliers off medical review.

The agency is looking to eliminate the deadline by which Medicare contractors would terminate nonrandom, prepayment, complex medical review to later than one year following the initiation of the medical review or when the provider or supplier has reduced the initial review error rate by 70 percent or more. This would mean that contractors would not be required to terminate nonrandom prepayment medical review by a prescribed time but would instead terminate each medical review when the provider or supplier has met all Medicare billing requirements as evidenced by an acceptable error rate as determined by the contractor.

The proposal, which is part of the revisions to payment policies under the physician fee schedule (currently on display and set to be published on July 30 in the Federal Register) would allow a contractor to set criteria that are lower—or higher—than the current requirement of one year or a 70 percent reduction in error rate, which was established in a final rule published on September 26, 2008, titled “Termination of Non-Random Prepayment Complex Medical Review.” While the Medicare Modernization Act mandated that CMS develop requirements for random prepayment reviews, the Health Care and Education Reconciliation Act of 2010 (HCERA) repealed the statutory requirements for the regulation.

A complex medical review requires that the contractor review medical record documentation and claims data to determine appropriate coding and billing before the claim is paid. Provider-specific complex medical reviews can suspend all claims from a particular provider or all claims related to a specific service or procedure submitted by that provider and are usually performed when the contractor has established that the provider has consistently billed an item, service, or procedure incorrectly. More information regarding complex medical reviews, as well as other types of Medicare claim reviews, can be found in the Physicians’ Compliance Guide.


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