Wiki Question on Medicare audits

[wynonna]

Hello:
How far back can Medicare go to check documentation for office procedures and documentation for ENT procedures?
I'm concerned that an element in endoscopies was not mentioned in procedure section which means a modifer 52 should have been attached.
I'm concerned Medicare will use this to downcode endoscopy procedures retroactively by 50%.

thank you

 

[jkyles]

Hi there, I'll start by saying that if a practice thinks it may have a significant amount overpayments it's best bet is to hire a health care attorney.

Second, under the Medicare Overpayment Rule practices are required to investigate suspected overpayments and there's a six year lookback period for doing so. www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/overpaymentbrochure508-09.pdf

Medicare has also has a six year limit on how far back it can go for audits but I believe that if the matter is escalated to a fraud investigation by the DOJ that period gets longer.

 

[amyjph]

It depends on the program being reviewed under. The number of years can vary.

https://www.cms.gov/about-cms/components/cpi

Medicare Fee for Service Recovery Audit Program | CMS

For updates regarding Medicare Fee-For-Service (FFS) medical review during the 2019-Novel Coronavirus (COVID-19) Public Health Emergency (PHE), please visit: https://www.cms.gov/files/document/provider-burden-relief-faqs.pdf (PDF)

www.cms.gov

 

[amyjph]

https://www.federalregister.gov/documents/2016/02/12/2016-02789/medicare-program-reporting-and-returning-of-overpayments