As you know, Medicare policy is a web of super-confusing rules and regulations. But for PTs, the majority of audits result from one of the following triggers: Excessive (i.e., above the norm) use of the KX modifier, which signals an automatic exception to the therapy cap on the basis of medical necessity
What is a Medicare claim review?
A Medicare contractor may use any relevant information they deem necessary to make a prepayment or post-payment claim review determination. This includes any documentation submitted with the claim or through an additional documentation request. (See sources of Medicare requirements, listed below). Who conducts the medical reviews?
What triggers a Social Security disability claim review?
The two most common triggers of a review of an individual’s Social Security disability claim or Supplemental Security Income claim (SSI claim) are A) work activity and B) medical review diary dates.
What is the purpose of medical review?
Medical review is the collection of information and clinical review of medical records by Medicare Contractors to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements. Medical review activities are directed toward areas where data analysis,...
What is the role of the CMS Medical Review?
One distinct role of the CMS Medical Review personnel is to provide contractor oversight such as: Providing broad direction on medical review policy. Review and approve Medicare Contractors' annual medical review strategies. Facilitate Medicare Contractors' implementation of recently enacted Medicare legislation.
What causes a Medicare audit?
What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.
What is a Medicare review?
Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.
What does it mean to be medically reviewed?
Medical review is the collection of information and clinical review of medical records by physician advisors (for providers reviewing cases before submissions) or a peer review team (for payers) to ensure that payment is made only for services that meet coverage, coding, and medical necessity requirements.
What are SNF medical review decisions based on?
Medical review decisions are based on documentation provided to support the coding and medical necessity of services recorded on the MDS for the claim period billed.
What is medical necessity review?
Medical necessity review means an assessment of current and recent behaviors and symptoms to determine whether an admission for inpatient mental illness or drug or alcohol dependence treatment or evaluation constitutes the least restrictive level of care necessary.
What review requires medical records?
Review of diverse medical records will be required including physician visits, hospital visits, admission summary, discharge summary, operative summary, lab reports and more.
What does a medical review nurse do?
As a medical record review nurse, you perform a utilization review of the coverage a patient received and help determine the medical necessity of each treatment. Your primary task in this role is to help minimize the costs of hospitalization or other treatments while still ensuring a high level of patient care.
How long does a medical peer review take?
two to four weeksThe usual recommended time for a review is two to four weeks. Sometimes, unforeseen circumstances arise that keep a reviewer from meeting a deadline. In such cases, the reviewer should contact the editor immediately. The editors then reassign the manuscript to alternative reviewers.
What's a clinical review?
Clinical Review means a process in which information about the Covered Person is collected and reviewed against established criteria to determine if the service, treatment or supply is Medically Necessary and is a Covered Health Service.
What are the three types of utilization review?
Utilization review contains three types of assessments: prospective, concurrent, and retrospective.
What makes a patient incompetent?
An individual determined to be incompetent can no longer exercise the right to accept or refuse treatment. Competency is a legal term referring to individuals “having sufficient ability… possessing the requisite natural or legal qualifications” to engage in a given endeavor.
What are the 4 medical decision making levels?
The four levels of medical decision making are: Straightforward (99202 and 99212) ▪ Low (99203 and 99213) ▪ Moderate (99204 and 99214) ▪ High (99205 and 99215) During an encounter with the patient, multiple new or established conditions may be addressed.
What do you need to know about Medicare audits?
1. There are three major audit-worthy red flags for physical therapists. As you know, Medicare policy is a web of super-confusing rules and regulations.
What is RAC in Medicare?
Developed as part of the Medicare Modernization Act of 2003, the RAC program reclaims money by conducting retrospective reviews of fee-for-service (FFS) claims—a process known as “claw back.”. For this initiative, the country is divided into four regions.
What happens if you fail to comply with a federal investigation?
If you fail to comply, you will not receive reimbursement for the claim.
What are the factors that trigger an audit of medical records?
Below are 10 factors that could trigger an audit of your medical records. 1. Patient Complaints. Payers provide hotline numbers to encourage patients to call if they believe they were billed for a service not received or that they were somehow treated unfairly. Make sure that you provide the first outlet for the patient to ask questions ...
What should be included in a physician's supporting documentation?
With the ever-increasing litigious environment and mandatory Congressional oversight of commercial and government payers, physician supporting documentation should emphasize and include the type of service (s) provided, the time involved, special technology and equipment used, as well as any other complications encountered.
Can ICD-10 codes trigger audits?
Sometimes high or excessive use of specific CPT codes and certain ICD-10 codes may also trigger audits. Be careful with the use of templates, especially in electronic records. Although templates are acceptable charting methods, they can look very repetitive, especially when it comes to routine care and services. Each chart note should clearly reflect the chief complaint, history, examination and treatment you rendered on that date for that patient.
Can non-participating providers bill Medicare?
Non-participating providers are permitted to bill the beneficiary up to the limiting charge amount , which is 115 percent of the allowed amount for participating providers who are paid 95 percent of the participating provider fee schedule amount. You may not charge Medicare patients more than the Medicare-established rate for any service.
What does CMS review?
CMS contractors medically review some claims (and prior authorizations) to ensure that payment is billed (or authorization requested) only for services that meet all Medicare rules.
When did CMS standardize reason codes?
In 2015 CMS began to standardize the reason codes and statements for certain services. As a result, providers experience more continuity and claim denials are easier to understand.
What is the second type of disability review?
The second type of review is a continuing disability review based upon work activity only. Work continuing reviews are most often triggered when an individual reports that they have gone back to work. Disability beneficiaries are required to report all work activity so that their disability file can be updated.
Why do disability cases have three year medical diary dates?
Most disability cases have three-year medical review diary dates because there is thought to be a chance of medical improvement. If an individual has an impairment that is unlikely to have medical improvement, they may have a seven-year medical review diary. Some disability beneficiaries have medical conditions that are likely to have medical ...
What is a CDR on Social Security?
Social Security performs two types of continuing disability reviews (CDRs), either separately or simultaneously: the work continuing disability review and the medical continuing disability review. These reviews are performed simultaneously when a disability claim comes up for medical review and the disability beneficiary has worked.
Do disability benefits have a medical review diary?
Some disability beneficiaries have medical conditions that are likely to have medical improvement so their disability claims may have medical review diary dates that are less than the standard three year medical review diary. All disability claims have medical review dates and individuals who receive disability benefits will most likely have more ...
Can you have more than one disability review?
All disability claims have medical review dates and individuals who receive disability benefits will most likely have more than one review in their lifetime. Most disability reviews result in a continuation of benefits for the disability beneficiary, so there is no reason to fear continuing disability reviews.
Can you be charged with fraud for not reporting work?
Under current Social Security guidelines, individuals who do not report their work activity may be sanctioned or even charged with fraud for not reporting their work activity. Essential Questions. What is the Social Security Disability SSI list ...
Do disability beneficiaries have to report work?
Disability beneficiaries are required to report all work activity so that their disability file can be updated. Work reviews may not cause any change in benefits for a disability beneficiary, or they may cause an individual’s benefits to be suspended or even terminated. Although most work reviews are triggered by Social Security beneficiary work ...
