On February 5, 2014, the Centers For Medicare and Medicaid Services sent out a transmittal (505) lifting the restriction on Medicare contractors, including Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and Zone Program Integrity Contractors (ZPICs), from taking action on claims that are "related" to but not included in claims currently under review, with an effective date of March 6, 2014.

This change now extends the reach of the MACs, RACs and ZPICs, especially concerning reviews of claims before or after the date of the claim in question.  As an example, an inpatient claim and associated documentation are reviewed and determined to be not reasonable and necessary and, therefore, the physician claim can be determined to be not reasonable and necessary.  Alternatively, a diagnostic test claim and associated documentation are reviewed and determined to be not reasonable and necessary and, therefore, the professional component can be determined to be not reasonable and necessary.

While the MACs, RACs and ZPICs can request additional information from providers before making a decision about a “related” claim, they are not required to.  Additional information may include medical documentation and other documents such as clinical evaluations, physician evaluations, consultations, progress notes, physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.

So what does this mean for you and your practice?  Will a denial of an inpatient stay lead to the denial of your physician services, requiring payback to CMS?  If an MRI ordered by a physician is deemed unnecessary, will the physician be held partly responsible financially for the lost reimbursement?  As a result of this policy change and as we get closer to the implementation of ICD-10 (October 1, 2014), it is more important than ever to have clear, accurate and precise clinical documentation so that the potential for denied claims is lessened.

Regards,

Stuart J. Glassman, MD

Please send your questions or comments to president@nhms.org or post a comment below.

Comments

Yes, I agree...documentation. My greater concern is....where is the outrage? We deserve the c$@# we are being served because of the spineless sheepleness of so many physicians. Frankly, it's professionally emabarrassing.