Who's 4th of 6 Medicare Contract Reviewers? - ✔✔-(SMRCs) Supplemental Medical Review Contractors
Who's 5th of 6 Medicare Contract Reviewers? - ✔✔-(ZPICs) Zone Program Integrity Contractors
Who's 6th of 6 Medicare Contract Reviewers? - ✔✔-(UPICs) Unified Program Integrity Contractor
What are the MACs Responsible for? - ✔✔-Performed Medical Reviews of IPPS claims since 2008.
What's the purpose of a medical Review? - ✔✔-Validates Medicare payments are made on claims that
are truly covered and correctly coded services and they are Med Nec
3 Types of Reviews? - ✔✔-*Automated
*Non Medical Record Review
*Medical Record Review "Complex Review"
, An automated review includes? - ✔✔-Electronic info to detect improper payments. "technical denials"
*Wrong info/ Incomplete info on the claim.
What's the MCE? - ✔✔-Medical Code Editor! It checks accuracy of code assignment prior to grouping.
ID's where an unacceptable code is used as P Dx, also when it's a duplicate or the p Dx and secondary
don't match w/ pt age or gender
What do CMS data mining tools do? - ✔✔-Compare submitted codes against unacceptable p Dx
NCCI - ✔✔-National Correct Coding Initiative.
* Non-complex review.
*ID's improper Coding that lead to Improper Payments, Accurate assignment of modifiers to prevent
denials
What 3 conventions are the coding policies based on? - ✔✔-*American Medical Association CPT manual,
*National And local Medicare policies and edits and *Coding guidelines developed by national societies,
standards and med
Non-medical Reviews? - ✔✔-*Manual intervention, determination based on only info included in claim,
*only performed on denials of related claims and
*when ADR is NOT submitted.
Complex Reviews? - ✔✔-Manual Review of health record! Medicare contract can review any info
necessary to make determination.
What will the contractor review to make the determination? - ✔✔-*Official coding guidelines.
*AHA coding clinic
*Medicare Program Manuals
*Other federal and local regulatory guidelines, this ensures claims are accurately coded.
*Billing hx and other info in file.
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