Practice Management Alert

Question: Do I need to worry about medical record reviews by the Centers for Medicare & Medicaid Services (CMS) even though we’re still in a public health emergency?

New Jersey Subscriber

Answer: Although the Centers for Medicare & Medicaid Services (CMS) put many investigations and reviews on pause during the pandemic, the agency is again looking into medical record reviews.

The agency may be looking at medical records of Medicare Parts A and B beneficiaries through additional development requests (ADRs) and targeted probe and education (TPE) programs for rationale to support skilled services, says Kris Mastrangelo, OTR/L, LNHA, MBA, president and CEO of Harmony Healthcare International.

You know CMS works with Medicare Administrative Contractors (MACs) for claims processing and other administrative functions. 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 form UB-04 and includes:

• HIPPS code
• ICD-10 code
• RUG level
• Dates of service

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