Saturday, September 4, 2010

Medicare Cert Appeals vs. Claim Adjustments

B. Cert Appeals vs. Claim Adjustments

Some Part A providers are cancelling claims and resubmitting adjusted claims when CERT alerts them via a Tech Stop or Non-Response Contact that documentation is missing or that a coding error has occurred.  Because these claims have been medically reviewed by the CERT contractor, providers are instructed to cease the practice of cancelling and adjusting claims that are selected in the CERT review process.

At the time of the Tech Stop or Non-Response Contact, the claim has been medically reviewed, but has not yet been denied.  Highmark Medicare Services will initiate the adjustments for any necessary denials.  When the CERT adjustment has been made in the FISS system, it will appear as an XXH type of bill.  If you need to make a correction or addition to the claim, providers may appeal the denials on the XXH type of bill.  The proper appeals process should be followed.

Providers should continue the practice of submitting an adjustment claim for an incorrectly billed line item, when the provider identifies the error outside of the medical review or CERT process.
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download