E/M Coding Alert - 2005 Issue 32
PRIOR DETERMINATION: More Certainty About High-Cost Items Could Be On Its Way
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Article Overview
This article covers a CMS proposed rule that would create a prior determination process for certain expensive Medicare physician services, along with criteria for building the initial service pool and timing for carrier responses. It is relevant to physicians, coders, practice managers, and compliance staff who need to understand Medicare coverage review processes, Federal Register rulemaking, and the types of services that may be affected. The article also notes how the proposal may interact with existing coverage policies and the CMS comment process.
Why This Topic Matters
The proposal could affect how practices handle uncertainty for high-cost services before they are furnished and may influence patient and provider decision-making around Medicare coverage.
Article Sections
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CMS proposal for prior determination
Introduces the proposed Medicare prior determination process and the general purpose of the policy. Summarizes the timing framework and the kinds of services being considered.
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How the initial service pool would be selected
Describes the criteria CMS proposed for choosing services for the initial pool and the role of existing coverage policies. Covers the possibility of future changes to the pool and differences tied to local policy variation.
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Perspective and comment period
Includes stakeholder reaction to the proposal and information about the public comment window. Notes the deadline and where comments could be submitted.
What You Will Learn
- What CMS proposed for prior determination of selected Medicare services
- How the initial set of services would be assembled at a high level
- How the proposal relates to existing coverage determinations
- What the article says about the public comment process
Who Should Read This
- Physicians
- Medical coders
- Coding managers
- Practice administrators
- Compliance staff
- Revenue cycle professionals
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