Wiki Medicare ADR Process Questions

[slgarland]

I am seeking detailed information on the Medicare ADR process. For instance, when the office receives an ADR and submits the physician notes, if the Medicare/Novitas auditor determines the notes do not meet the originally billed level of service ex: 99223, will Medicare/Novitas downcode the charge and release payment or is the charge denied with zero payment?
In addition, does Medicare/Novitas keep track of how many cases result in downcodes and are they "held against" the physician, leading up to a pre-payment audit?
Right now the process in the office is to receive the ADR, do an internal audit of the notes, if the notes are scored differently than the charge originally submitted by the physician the ADR is allowed to "time out" and then an appeal is submitted to Medicare/Novitas with a new code.

 

[thelton]

Novitas will down-code the claim to what they feel is the correct code. I definitely would not recommend letting the ADR "time-out"; I feel that practice would put you on their radar more than if they down-code some claims. Also, if they do down-code a claim, be sure to audit it yourself; I have successfully appealed several claims the Novitas auditor down-coded. I use their own audit form and color-annotate the notes showing exactly how I audited the note.

 

[dyates]

CMS Chapter 34 manual Reopening and Revision of claim determiantion and decesions may help answer your questions.