CHA News Article

CMS Guidance Allows Auditors to Deny “Related” Claims
Effective Sept. 8

The Centers for Medicare & Medicaid Services (CMS) has issued the attached transmittal stating that Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) have the discretion to deny “related” claims submitted before or after the initial claim in question, subject to CMS approval. Claims are considered “related” if documentation associated with one claim can be used to validate another claim. The guidance is effective Sept. 8.

CMS provides an example of a related claim that may be denied in the situation where the MAC performs post-payment review/recoupment of the admitting physician’s and /or surgeon’s Part B services. For services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services that could have been provided as outpatient), the MAC reviews the hospital record, and if the physician service was reasonable and necessary, the service will be re-coded to the appropriate outpatient evaluation and management service. For services where the patient’s history and physical, physician progress notes or other hospital record documentation do not support the medical necessity for performing the procedure, post-payment recoupment will occur for the performing physician’s Part B service.

The MAC and ZPIC must await CMS approval prior to initiating requested related claims review. Upon CMS approval, the MACs will be required to post their intent to conduct related claim reviews to their website within one month of initiation.

CHA urges member hospitals to review the details in the related transmittal. CHA will also reach out to Noridian for additional information regarding next steps.

CMS will host a call providing details on Sept. 9 at 10:00 a.m. (PT). To register, visit http://www.eventsvc.com/blhtechnologies/register/120d09b7-db70-48ea-a2f5-5ed4fa3b250e.

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