As a reminder, Health New England is undertaking an initiative to ensure our claims payment and pricing systems align with CMS rules. The Centers for Medicare & Medicaid Services (CMS) has a process for Medicare coverage determination. This includes National Coverage Determinations (NCDs), which are determined through an evidence-based process. In the absence of a national coverage policy, we may cover a service at the discretion of the Medicare contractor using Local Coverage Determinations (LCD).<\/p>\n
In the 4th quarter of 2022, the following edits will be implemented:<\/p>\n
Same Day Visit<\/strong> \u2013 (professional services) \u2013 Identifies Procedure Codes billed by the same provider on the same date of service as a code with a global period.<\/p>\n Global Component<\/strong> \u2013 (professional and outpatient facility) \u2013 This rule identifies claim lines with procedure codes that have components (professional and\/or technical). The rule also detects when duplicate submissions occurred for the total global procedure or its components across different providers.<\/p>\n The following scenarios are audited:<\/p>\n <\/p>\n CMS Status Indicators<\/strong> \u2013 (professional services) \u2013 Claim lines containing procedure codes with a status indicator defined by CMS on the Medicare Physician Fee Schedule (MPFSDB).<\/p>\n\n