August 21, 2014

CMS Transmittal Addresses Denial of ‘Related’ Claims

The Centers for Medicare & Medicaid Services (CMS) has issued Transmittal 534 to the Program Integrity Manual. Dated Aug. 8, the transmittal allows Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICS) discretion to deny other "related" claims submitted before, or after, the date of the claim in question. If documentation associated with one claim can be used to validate another claim, those claims may be considered "related."

As an example, for services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services could have been provided as outpatient or observation), the MAC reviews the hospital record. If the physician service was reasonable and necessary, the service will be recoded to the appropriate outpatient evaluation and management service. For services where the patient's history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, post-payment recoupment will occur for the performing physician's Part B service. Contact Kathy Reep, vice president of financial services, at (407) 841-6230 for more information.