Pathology/Lab Coding Alert

Question: I’ve heard that CMS is suspending medical reviews for the duration of the COVID-19 public health emergency. Is that correct?

Codify Subscriber

Answer: Although CMS initially suspended Medicare fee-for-service (FFS) medical claims reviews on March 30 due to COVID-19 Public Health Emergency (PHE), the suspension has ended.

The PHE was extended: https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-23June2020.aspx

Details: The initial suspension included pre-payment medical reviews that Medicare Administrative Contractors (MACs) performed under the Targeted Probe and Educate program, as well as MAC’s post-payment reviews, Supplemental Medical Review Contractor (SMRC) reviews, and Recovery Audit Contractor (RAC) reviews.

Now CMS states in an FAQ available at www.cms.gov/files/document/provider-burden-relief-faqs.pdf that reviews would resume on August 3 — regardless of the status of the PHE at that time.

CMS emphasizes that the agency will discontinue exercising enforcement discretion due to “the importance of medical review activities to CMS’ program integrity efforts” as states reopen.

The FAQ specifies, “If selected for review, providers should discuss with their contractor any COVID-19- related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.”