As of May 4, 2015, Medicare auditors will be able to upcode and downcode claims when they believe the provider has selected an incorrect code, while still rendering a payable service. This change comes from the new Centers for Medicare and Medicaid Services (CMS) transmittal 585, allowing Medicare auditors to change the level of codes instead of denying them. The changes apply to:
Medicare administrative contractors (MACs),
- Recovery auditors (RACs)
- Zone program integrity auditors (ZPICs)
- Supplemental medical review contractors (SMRC)
- Comprehensive error rate test contractors(CERT)
The positive aspect of auditors being able to upcode and downcode claims is that providers will receive some type of payment for the services rendered without having to appeal. To learn more about transmittal 585 and how it might affect your practice, visit the CMS Regulation and Guidance site.