Practice Management Alert

Plus, resubmit if you were a victim of the Humana claims edit that resulted in 450,000 rejections.

Practices have long wondered how far back payers can go when requesting medical records for review. For Medicare, the answer has been 12 months. But that all changes soon -- on June 26 to be exact.

How it works now: 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.

The news: In Transmittal 422, which will go into effect on June 26, CMS states it 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.

Humana recently notified a number of its physicians that a glitch in a claims edit relating to version 5010 implementation cause roughly 450,000 claims to be rejected. The affected claims were submitted to Humana's clearinghouse, Availity LLC, between April 26 and May 10 of this year.

Availity rejected claims after Humana asked the clearinghouse to begin enforcing a new 5010 claims edit for linking diagnosis and procedure codes. CMS, however, recently announced it would reevaluate this particular edit requirement and Humana has instructed Availity to relax the edit until CMS issues new guidance. Humana has suggested that physicians resubmit any claims that were affected by the edit enforcement.