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Q&A: You've got questions! We've got answers!

Physician Practice Insider, June 12, 2017

Q: Can a claim that is edited for a noncovered procedure be appealed?

A: If a claim is edited for a noncovered procedure, the claim cannot be submitted to CMS for appeal. Therefore, once the coding of the noncovered procedure is validated, the process to split the noncovered procedure onto a sepa¬rate claim must be followed so that at least one claim can be submitted and processed. Then an appeal can be filed if the provider actually believes the procedure should be or is covered. With version 33 of the Medicare Code Editor (MCE), the first version of the MCE using the ICD-10 codes, CMS acknowl¬edged errors in this list of noncovered procedures and provided instructions to Medicare Administrative Contractors to process claims having the errors as described in the IPPS

For more information, see The Chargemaster Essentials Toolkit.

Editor’s note: Email your questions to Editor Karen Long Rayburn at klong@decisionhealth.com.

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