Medical Review - JE Part B

Q1: Is it okay to change the codes I’m billing when I find out that I am on a Medicare review of records?
A1: It is inappropriate to change billing patterns because of being on a review by Medicare. The coding of a claim should be based on the body of the documentation. The practice of changing billing patterns may be fraud or abuse. Refer to: Medicare Program Integrity Manual (MPIM) chapter 3, 3.2.7 (E) and Chapter 4, Section 4.2.1., Fraud and Abuse

Q2: Why does a diagnostic provider have to submit a progress note from the ordering/referring provider? It is so hard to get these documents as they are not provided with the order.
A2: Per 42 Code of Federal Regulations (CFR) 424.5(a)(6) "(6) Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment." The eCFR :: 42 CFR 424.5 -- Basic conditions and the Medicare Program Integrity Manual (MPIM), "Unless otherwise specified, the MAC, RAC and UPIC shall request information from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested documentation. However, because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and UPIC".

Q3: What are the different options for submitting documentation?
A3: When a Medicare claim requires documentation to be submitted for review, the contractor will send an Additional Documentation Request (ADR) letter requesting the provider to send documentation that supports the claim(s) being billed. Providers receive notice of an ADR by mail or electronically, depending on the providers preference. Responses should be returned promptly to avoid processing delays and must be submitted within the timeframe documented in the letter to avoid claim denials. Providers have 45 days to respond (from the date on the letter) to the ADR. Documentation can be submitted thru the Noridian Medicare Portal, fax, postal mail, CD submission or electronic submission (esMD). Refer to: How to Respond to ADR

Q4: What are the timeliness requirements for initial and subsequent certifications?
A4: In outpatient locations, the timeliness standard for certification of the initial POC is that it must be completed by the therapist and signed by the practitioner within 30 days of initial treatment under that plan (unless delayed certification requirements are met).

Recertification of subsequent POCs must be completed by the therapist and signed by the practitioner during the duration of the prior POC or within 90 days, whichever is less, unless delayed certification requirements are met. When a practitioner signature is not dated, but documentation includes the date the signed document was faxed from the practitioner’s office back to the therapy provider, we can infer the faxed date and signature date are the same. Faxed certifications/recertifications need to have clear documentation to support the practitioner had access to review each of the required POC elements. All signatures must still be legibly dated to support that timeliness standards are met. References: Medicare Program Integrity Manual