Part B Insider (Multispecialty) Coding Alert

Published on Mon Jan 19, 2015 PDF

When you get a documentation request from your MAC or another Medicare entity (such as a ZPIC, CERT or RAC auditor), chances are strong that you don’t have the requested paperwork sitting right in front of you—but if you need more time than the standard 45 days to find it, you can say goodbye to your payments.

That’s the word from new MLN Matters article MM8583 entitled “New Timeframe for Response to Additional Documentation Requests,” which goes into effect on April 6. It notes that when an auditor needs additional documentation from your practice, “no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period.” This indicates that the payer will freeze your payments until you come forward with the documentation.

Although that was always the case, the article points out what is new with the policy: Auditors have always expected documentation for pre-payment review within 45 calendar days of the request, but in the past may have granted extensions when warranted on a case-by-case basis. Now CMS says, “The reviewer should not grant extensions to the providers who need more time to comply with the request.”

Not only will you get denied for extra time, but you can expect to collect nothing on the claims if you don’t get your documentation in before the 45 day period expires. “Reviewers shall deny claims for which the requested documentation was not received by day 46,” CMS says.

Resource: To read the article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8583.pdf.