Pathology/Lab Coding Alert

Question: We’d heard that medical records reviews were on hold due to the COVID-19 PHE, which is still in effect, but have MACs started them up again?

Washington subscriber

Answer: Although it is true that Medicare Administrative Contractors (MACs) paused many investigations and reviews earlier in the COVID-19 public health emergency (PHE), the administrators are again performing medical record reviews.

MACS may be looking at Part A and Part B claims through additional development requests (ADRs) and targeted probe and educate (TPE) programs.

Tip: Under TPE, MACs focus on providers with high claims denial rates or providers who have billing practices that vary greatly from their peers. Read more about TPE at www. cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-QAs.pdf.

Bottom line: Your MAC should be your key connection for questions and would be the initiator of medical records reviews and the first level of appeals adjudication.