decisionhealth Newsletters, Part B News - 2015 Issue 4 (April)
Medicare auditors given powers to upcode, downcode claims rather than deny them
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Article Overview
This article covers a CMS policy update affecting Medicare audit review processes and the handling of selected claims by MACs, RACs, ZPICs, SMRC, and CERT contractors. It is written for billing, coding, compliance, and practice management audiences who need to understand how audit adjustments may affect claim payment, documentation review, and evaluation and management service reporting. The discussion focuses on the operational and compliance implications of the change, including documentation relevance, subjective E/M review concerns, and examples of when claim adjustments may be made instead of denial.
Why This Topic Matters
The policy shift can change how audit findings affect payment and appeals, which matters for reimbursement, documentation practices, and compliance readiness. It also highlights the importance of supporting billed service levels with documentation that matches the encounter.
Article Sections
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CMS transmittal and audit authority update
Introduces the CMS transmittal and the revised authority granted to Medicare audit contractors when a payable service was rendered but the billed level appears incorrect. It sets the policy context and identifies the contractor types affected.
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How the change affects providers
Describes the practical impact on providers, including payment, appeal considerations, and concerns about review outcomes. It also discusses how the policy may influence billing behavior and audit response.
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Ensure documentation is relevant to visit
Focuses on documentation expectations in audit review and the importance of aligning recorded work with the reason for the encounter. It addresses the general role of medical necessity and encounter-specific support in E/M documentation.
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Some cases not subjective
Summarizes non-subjective situations described in the article where a mismatch between billed and documented services may be identifiable on review. It includes a brief reference example illustrating the type of claim adjustment discussed.
What You Will Learn
- What the CMS transmittal changes about Medicare audit claim handling
- Which Medicare audit contractor types are affected
- How the policy may influence payment, denial, and appeal outcomes
- Why documentation relevance matters in E/M audit review
- What kinds of claim mismatches may be adjusted during review
Who Should Read This
- Medical coders
- Billers
- Compliance staff
- Practice managers
- Physicians and other clinicians
- Revenue cycle professionals
Codes Discussed
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