Claims reprocessing: What you need to know

By Kelly Byrnes, FSVU, RVT, BS posted Wed March 28, 2018 03:06:24 PM

We recently posted an article on the SVU website about changes to the Medicare program that affects many of our members. If you are a provider billing Medicare Part B, here is what you need to know:

1) On December 27th, a correction notice (CMS 1678-CN) was issued affecting 3 vascular codes (93880, 93930 and 93978) paid under the Outpatient Prospective Payment System (OPPS). In turn, these changes impacted Part B of the Medicare Physician Fee Schedule (MPFS), since the codes are capped by the OPPS.

2) The MPFS payment files given to Medicare Administrative Contractors (MACs) did not reflect the updated rates in the OPPS, as of January 1st. Therefore, providers who provided these services and billed Medicare Part B were underpaid.

3) CMS corrected these rates in new MPFS files and informed the MACs of the corrections on February 12, 2018. Note: SVU continued to work with CMS as there were still incorrect files in some states and localities. These files were not corrected until early March. On March 19th, CMS assured SVU that all files had been corrected.

4) The corrected files also contain other updates as a result of the Bipartisan Budget Act of 2018, which was signed into law on February 9, 2018. Depending on where you practice, you may be impacted by these updates too. Those updates are not addressed here.

5) The good news: MACs will automatically reprocess claims impacted by the OPPS cap for dates of service in Calendar Year 2018. The MACs will reprocess claims which cannot be automatically reprocessed only if you bring such claims to your MAC’s attention.

6) The bad news: MACs have 6 months to ensure reprocessing of claims.

I am asking everyone impacted by the incorrect payment files to monitor claims closely. Please let me know if you have any questions!