Pathology/Lab Coding Alert

Question: Communications from our Medicare contractor are so full of “alphabet soup” that half the time I don’t know what they’re talking about. Can you provide some definitions for some common acronyms that I should know relating to reimbursement?

Codify Subscriber

Answer: Sure. Your Medicare Administrative Contractor (MAC) administers Part A and Part B Medicare claims for your geographic region. The following list provides some of the common acronyms that you should be familiar with:

• ACT – The Medicare Modernization Act (MMA) mandates “Ask-the-contractor” teleconferences, which are also known as ACTs. These group chats organized by MAC outreach consultants assist both Part A and Part B providers with answers and advice to questions on a particular timely topic and are part of a CMS education effort on Medicare changes.
• EOB – The Explanation of Benefits (EOB) is a form that insurers send patients after they process a medical claim. Patients often mistake the EOB for a bill, but it is not. Instead, it is a detailed explanation of the claim and services rendered.
• IOM – Internet-only Manuals (IOMs) are defined by CMS as “a replica of the agency’s official record copy.” What that means is that IOMs cover the Medicare daily posts, rulings, policies, and updates to procedures and coverage—guidebooks for understanding CMS.
• LCD – A Local Coverage Determination (LCD) relates to MAC limitations placed on particular items and services under its distinct jurisdiction.
• MSP – Medicare Secondary Payer (MSP) refers to the process of payment when Medicare is the second insurer after another entity who holds the primary payment responsibility.
• NCD – National Coverage Determinations (NCDs) pertain to the nationally recognized information  on coverage for a service or item. CMS provides extensive laboratory NCDs.
• OCA – An Overpayment Claims Adjustment (OCA) happens when Medicare determines that a provider has been overpaid for care given. The OCA is the process that occurs to rectify the overpayment to be paid back to Medicare.
• RA/ERA – Remittance Advice (RA) or the Electronic Version (ERA) is sent to providers after a claim has been submitted to the MAC. The RAs or ERAs are itemized and offer information about the payment and any adjustments made by Medicare.
• SIA – Supplemental Instructional Articles (SIA) are coding guidelines that explain a service, LCD,  or CMS coverage in more detail and cover an individual MAC’s rule.

Resource: For a quick overview of MACs and the link to the complete and current lists to access more information, visit https://www.cms.gov/medicare/medicare-contracting/medicare-administrative-contractors/medicareadministrativecontractors.html.