It’s important to know about claims and the medically unlikely edits, and what happens in the long run if you get hit with one of these edits. Depending on the claims processing system that your contractor uses, you may receive a denial. You may receive it as an RTP or return to provider if your contractor uses the FISS, the Fiscal Intermediary Share System, to process claims. Or you may receive it as an actual denial if they're using the Medicare Claims System, the MCS. It’s possible that you may or may not know what system your contractor is using. You'll be able to tell based on how your claims come back, if you have submitted a claim that was subject to an edit and it ends up coming back to you. So, once you get that claim back, you will then proceed on how you want to take care of it to either fix it or appeal it and what's the appropriate mechanism. If you have a contractor that is using the FISS system, you're going to have your claims RTP or return to provider. And I'm sure you're probably familiar with that if you work in the billing setting, in the finance setting on the hospital side or on the physician side as well, you're probably pretty familiar with RTPs and you know, how that comes back to you if there's an error that they've returned. They've just returned the claim. They haven't processed it.
So in this case, if you've got a claim that's RTP or return to provider, you cannot appeal that claim. And the reason you cannot appeal it is because it haven't been processed so it hasn't been denied. And if there was a problem and we are unable to even enter the claim, you know, potentially there were codes missing or something blatantly wrong, we would put it in an envelope and send it right back to them. And that's the electronic equivalent of that putting in an envelope and sending it back to the provider as RTP. You cannot appeal those.
Correct Coding and Resubmitting the Claim
If you've got a claim back that RTP and it's due to a medically unlikely edit, you want to take a look at the claim. To check, what did you do wrongly? Did you bill it improperly? Did you inappropriately put in the wrong number of units? For instance, did you bill for 780 units of something by putting the diagnosis code into the unit of service field? Or did you just calculate it wrong? Take a look at it and if it was billed improperly, if you had put the inappropriate number of units, et cetera, then just corrects the coding and resubmits the claim, being aware that, you know, the potential exists that they may request documentation – those kinds of things. Those are the types of things that can get caught up in an audit in the long run. So you want to make sure that your documentation is well supportive of whatever the corrected coding is. If you get that RTP and you find that it wasn't billed improperly, that it was billed - that you did mean to bill that number of units for that particular service and the medical necessity exist for that increase in unit, then you need to take a look at it and correct the coding. Now, by correcting the coding most likely that means that you're going to be adding modifiers. You probably did not add the modifiers the first time around so you're going to be probably add modifiers to that claim. But, you know, if it's billed improperly, correct the coding, resubmit, you know, if you put the wrong number of units or what not. But if it wasn't billed improperly, if the number of units was accurate, then chances are that you'll need to correct that coding by using appropriate modifiers and then resubmitting the claim.
The best way to find answers to your queries regarding medically unlikely edits is found in FAQ section of cms.hhs.gov. Type in to the subject box, medically unlikely edits, it will actually bring out an entire section of questions and answers, frequently asked questions on these edits. Plus, Medicare actually does a very good job of updating these on a regular basis. So, if you do have questions, you're not positive on what to do with something and you don't have any other resource to go to, you can always take a look there and see if there's something on their website. There's oftentimes helpful information there.
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