Timeframe to adjust a claim
APCs Insider, July 23, 2004
Want to receive articles like this one in your inbox? Subscribe to APCs Insider!
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 Insider!
Related Products
-
Briefings on APCs
Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...
-
HIM Briefings
Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...
-
Briefings on Coding Compliance Strategies
Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...
-
Briefings on HIPAA
How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...
-
APCs Insider
This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...
Most Popular
- Articles
-
- CMS puts hospital surveys on limited hold as surge continues
- Don't forget the three checks in medication administration
- Practice the six rights of medication administration
- Note similarities and differences between HCPCS, CPT® codes
- Q&A: Primary, principal, and secondary diagnoses
- The consequences of an incomplete medical record
- Nursing responsibilities for managing pain
- Skills of effective case managers
- ICD-10-CM coma, stroke codes require more specific documentation
- OB services: Coding inside and outside of the package
- E-mailed
-
- CMS puts hospital surveys on limited hold as surge continues
- Charge and bill Medicare all pre-operative diagnostic tests
- How to create a safety protocol for emergency department psychiatric patients
- Know guidelines and subtle differences in code descriptions for laceration repairs
- Q&A: Mechanical room storage, risk assessments, patient rooms
- Modifier -25: Is that E/M service really above and beyond the norm?
- Long-Term Care Training Solutions
- Injections and infusions continue to confuse coders
- Get the facts on emergency department FAST exams
- Capturing start and stop times for infusions
- Searched