Otolaryngology Coding Alert

Question: Does our practice need to worry about medical record reviews by the Centers for Medicare & Medicaid Services (CMS) since the COVID-19 public health emergency (PHE) is still ongoing and may be extended through the end of the year?

Florida Subscriber

Answer: While CMS put many investigations and reviews on pause during the pandemic, the agency is again looking into medical record reviews.

The feds may be scrutinizing medical records of Medicare Parts A and B beneficiaries through additional development requests (ADRs) and Targeted Probe and Educate (TPE) programs for rationale to support skilled services, says Kris Mastrangelo, OTR/L, LNHA, MBA, president and CEO of Harmony Healthcare International.

CMS works with Medicare Administrative Contractors (MACs) for claims processing. Your respective MAC would probably be a key connection point in assisting CMS with local claims, as well as reviewing the first level of appeals adjudication functions, Mastrangelo says.

Most of the medical record information that may be reviewed can be found on the CMS-1500 form and includes:

• ICD-10-CM codes
• Date(s) of service
• National Provider Identifier (NPI) information

Note: Telehealth claims have also been under the microscope in CMS audits. So, make sure your documentation fully demonstrates the medical necessity and includes the method of the telehealth visit (audio/video or audio only), those in attendance, and time expended during the encounter for all audio and audio/video visits that are coded based on time.

Resource: Check out this CMS guidance at www.cms.gov/ Research-Statistics-Data-and-Systems/Monitoring-Programs/ Medicare-FFS-Compliance-Programs/Medical-Review/ Downloads/TPE-QAs.pdf.