Industry Notes: CMS to Start Denying Claims That Don't Meet Ordering/Referring Edits 'Soon'

Why This Topic Matters

The update helps practices track policy shifts that can affect claim acceptance, lab test billing, documentation review, and compliance planning. It is especially relevant for organizations that submit Medicare claims or manage coding, billing, and audit risk.

Article Sections

1. CMS ordering/referring provider edits

   Discusses an upcoming Medicare claims-processing change involving ordering and referring provider edits and the operational implications for providers.

2. CMS grants CLIA-waived status to additional lab tests

   Summarizes CMS guidance on newly classified CLIA-waived laboratory tests and the related billing update for Part B practices.

3. Cardio office visits are on the OIG radar

   Reviews OIG scrutiny of higher-level evaluation and management billing patterns and the compliance concerns raised for physician practices.

4. Affordable Care Act already having effect

   Covers commentary on early policy and market effects tied to the Affordable Care Act, including coverage and compliance developments.

5. Don't count on ICD-11 transition

   Explains why a near-term transition to ICD-11 is viewed as unlikely and highlights the implementation and rulemaking considerations discussed by industry sources.

6. Private payer partnership bolsters government's compliance efforts

   Describes a public-private effort intended to improve fraud detection and share information across payers and enforcement stakeholders.