Medicare Compliance & Reimbursement

CMS nixes the one-year lookback period effective June 26.

Part B MACs now have more flexibility than ever in requesting older documentation from your practice during claims audits, according to a new CMS transmittal, which removes the 12-month lookback timeframe.

Background: Currently, if a MAC requests your records related to claims that are under review, the MAC can collect documentation "related to the beneficiary's condition before and after a service, but shall not request documentation dating from more than 12 months prior to the date of service unless an exception exists," according to Section 3.2.3.4 of the Medicare Program Integrity Manual.

New way: Last week, CMS issued Transmittal 422, which will go into effect on June 26. The directive will do away with that 12-month lookback period, and does not replace it with a new one. Therefore, the Manual implies that records can be requested indefinitely from the date of service, although it's not completely clear in the document whether any deadline will be introduced to replace the previous 12-month limit.

Example: You perform a hip replacement on July 1, 2012. In the past, your MAC could request the documentation from that surgery until July 1, 2013, but now you shouldn't be surprised if you get a record request in August -- or afterward.

The reality is that you most likely retain medical records for much longer than one year anyway, since state statutes of limitation dictate how long you must retain them. In New York, for example, even if a patient leaves your practice you must keep his records for six years after the last visit, whereas in Michigan the records must be kept for seven years.