The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS

National Government Services Articles for Part A & B ProvidersAppeals for Inpatient Hospital Medical Review DenialsDecember 2010The National Government Services Appeals Department has received a large volume of appeals based onthe medical review of inpatient hospital claims. An educational opportunity has been identified due to aportion of these appeals being inappropriate requests.IssueProviders are submitting/requesting an appeal on the denied inpatient claim, and in the appeal they arerequesting appeals to change the claim to an outpatient claim (13X bill type). When an inpatient stay isdenied as “not medically necessary” providers may submit an outpatient claim for the covered Part Bservices.* Providers may not change the patient status on appeal or after discharge. Requesting a 13X billtype is requesting a change in patient status; as if the inpatient admission never occurred. ConditionCode 44 is not applicable in this scenario.Resolutions• Providers do not need to request an appeal on an inpatient claim unless they disagree with themedical review determination of noncoverage for the inpatient portion.• Providers may not adjust a claim under or after medical review.• Providers may, after receiving the medical review denial, submit a 12X bill type for the covered PartB services. A 12X bill type is handled as an outpatient claim but does not change the patient status; itis an inpatient Part B only claim. This bill type recognizes the noncoverage or unavailability of Part Abenefits.• With the submission of a 12X claim after an inpatient denial, the Part A portion remains providerliable based on the medical review determination.Additional Observation and Condition Code 44 Resources• The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 1 Section 50.3 (2.2 MB)• Observation article under the Clinical Education section of www.NGSMedicare.com* Medicare pays under Part B for physician services and for nonphysician medical and other healthservices listed in Section 240 above when furnished by a participating hospital to an inpatient of thehospital when patients are not eligible or entitled to Part A benefits or the patient has exhausted their PartA benefits.• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 4 Section 240.1 (921 KB)Billing and Documentation Instructions for Use and Administration ofLumizymePlease refer to the following guidelines when submitting documentation for use and administration ofLumizyme (alglucosidase alfa):• Be sure to include not only clinical notes related to the administration of the drug on the day ofadministration, but also the required background data and testing information. The recordsshould reflect the fact that cardiac hypertrophy was not present prior to beginning the patient’sCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 4 MMR 2011-01, January 2011