Timeframe to adjust a claim
APCs Weekly Monitor, July 23, 2004
Want to receive articles like this one in your inbox? Subscribe to APCs Weekly Monitor!
QUESTION: How long does a hospital have to submit an adjustment claim to Medicare for an Outpatient Prospective Payment System (OPPS) claim that was incorrectly coded?
ANSWER: The Centers for Medicare & Medicaid Services (CMS) recently published an explanation on this very issue. Medicare Claims Processing Pub. 100-4, Chapter 3 Inpatient Hospital Billing, Section 50 Adjustment Bills, states that the timeframe for submitting an adjustment claim on a timely filed original claim falls under the "administrative finality rules." This means that until your hospital's cost report is finally settled for that year, the claim can be adjusted.
Realistically, the claim may have been sent to history on your fiscal intermediary's system and you may need to "reactivate" it in order to perform an online adjustment-but it is still possible to adjust OPPS claims back to the beginning of the program (August 2000) for most providers. Although the section of the manual states "Inpatient Hospital Billing," the adjustment claim reasons include HCPCS codes that are only valid on outpatient and Part B only claims that are covered by OPPS.
In the past, it was commonly assumed 18 months was the time allowed to resubmit a claim because that is the timeframe for timely filing of an initial claim. Until recently, CMS had not published anything with regard to claim resubmission timeframes. Note that open cost reports can stretch on for years until they are finally settled. To determine whether a cost report remains open, contact the hospital's reimbursement manager.
For more information, refer to this Special Edition Medlearn Matters article (SE0420) regarding MMA Section 937, "Correction of Minor Errors and Omissions Without Appeals" at www.cms.hhs.gov/medlearn/matters.
Want to receive articles like this one in your inbox? Subscribe to APCs Weekly Monitor!
Related Products
Most Popular
- Articles
-
- HealthDataInsights posts new issues for medical necessity claims
- New FAQ posted on storing laryngoscope blades
- Q&A: Incidental disclosures and patient privacy
- What does case-mix index mean to you?
- Tip of the Week: Treat faculty orientation like resident orientation
- Capturing all necessary codes for IUD insertion and removal can be challenging
- Topic: CMS, OESS post new security compliance review information, checklist
- Q/A: New device pass-through categories
- 2012 CPT code changes for ASCs: Shoulder and knee scopes and pain management
- News and briefs: GA may increase residency number s across state, but cut main hospital?s budget
- E-mailed
-
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- What does case-mix index mean to you?
- Tip: Know the common bunionectomy procedure codes and how to use them
- Code changes should help ease the pain when coding for facet joint injections
- Documentation and coding for toxic metabolic encephalopathy
- News and briefs: UA study links lack of empathy in residents to long shifts
- OB services: Coding inside and outside of the package
- Don't let improper discharge disposition codes fly under the radar at your facility
- Discharge Planning Under the MDS 3.0
- Correctly code for new cardiac, pulmonary rehab benefits
- Searched