General Surgery Coding Alert

All practices billing Medicare should act now to get a strong handle on Medicare's "revalidation process." For those practices not in compliance, your carrier or fiscal intermediary (FI) may very well pull the plug on your billing privileges.

Background: According to CMS ruling 42 CFR 424.515 in the April 21, 2006, Federal Register, all Medicare providers must revalidate their Medicare information on file, via a CMS-855 form, within 60 days of receiving a revalidation request from their CMS fiscal intermediary or carrier, say Lyndean Brick, JD, senior vice president of Murer Consultants Inc. in Joliet, Ill.

That sounds simple enough, but many providers have never filed a complete CMS-855 -- which can make the revalidation process quite difficult, Brick says.

But that's not all: "Generally speaking, after a provider submits a complete CMS-855, either in response to a revalidation request or otherwise, the provider must then revalidate his or her entire CMS-855 filing once every five years -- or within 90 days after any change in his or her Medicare provider information," Brick says.

If you-re not sure what kind of information you need to have lined up for CMS for revalidation, check out a copy of the Medicare enrollment form online at http://www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf. You may see that pieces of this required information are out of date for your practice or facility, and if that's the case, you should fix that fast and submit a fresh 855 form to CMS.

As you update your information, consider consistency a top priority. "One of the biggest problem areas we find is that providers aren't consistent with names, among other things, in their legal documentation," Brick says.

Critical: And now, with national provider identifiers (NPIs) going into full-swing, the practice or facility name and other information you-ve filed on your NPI application must match your legal documentation. "Even if one little thing gets out of whack and CMS catches it, its contractors can stop reimbursement," Brick says.

The CMS revalidation process is being enforced over a five-year period that went into effect last year, and the initial revalidation effort focused on Medicare contractors- top-100 billers. "CMS will continue to push forward with its revalidation efforts with smaller organizations as the effort phases in," Brick says.

Going forward: From here on out, anytime you have even the slightest change in your legal information, even something as small as an address change, you need to notify Medicare of that change within 90 days.

See for yourself: To view the complete rule, see the April 21, 2006, Federal Register online at edocket.access.gpo.gov/2006/pdf/06-3722.pdf.