Medicare Billing Updates: GZ Modifier, Timely Filing, Reprocessing Claims
CMS Transmittal 2148 (CR 7228) published February 4, 2011, notifies providers that Medicare will automatically deny claim line items submitted with a GZ modifier, effective for dates of service on or after July 1, 2011. Also, Medicare contractors will not perform complex medical review on any claim line item(s) submitted with the GZ modifier. This includes Medicare administrative contractors (MACs), recovery audit contractors (RACs), Comprehensive Error Rate Testing (CERT) reviewers, Zone Program Integrity contractors (ZPICs) and Program Safeguard Contractors (PSCs). The GZ modifier is appended to a line item when the provider did not issue an Advance Beneficiary Notice (ABN) to the patient, but expects the service to be denied due to a lack of medical necessity. For more information, see the transmittal at the link above or MLN Matters Article MM7228.
The Affordable Care Act (ACA) changed the Medicare timely filing limits. Effective for services furnished on or after January 1, 2010, all claims for Medicare Fee-For-Service providers must be submitted no later than 12 months (one calendar year) after the date the services were furnished. For span date claims from institutional providers, the “Through” date on the claim is used for determining the date of service for claims filing timeliness.
CMS Transmittal 2140 establishes certain exceptions to the timely filing limits. For the following conditions Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the condition occurred:
- Administrative error or misrepresentation by a Medicare employee, contractor, or agent
- Retroactive Medicare entitlement
- Medicaid Agency recoupment of payment due to retroactive Medicare entitlement
- Retroactive disenrollment from a Medicare Advantage plan or a PACE provider organization
For more information, see MLN Matters Article MM7270.
Reprocessing Claims Affected by the ACA or 2010 MPFS ChangesVarious provisions of the Affordable Care Act (ACA) and corrections to the 2010 Medicare Physician Fee Schedule (MPFS) were implemented some time after their effective dates. Due to the retroactive effective dates, a large volume of Medicare fee-for-service claims will need to be reprocessed. CMS is beginning this automatic reprocessing, but expects this effort to take some time. Medicare requests that providers not resubmit these claims because they will deny as duplicate claims and slow the retroactive adjustment process. Since Medicare pays the lesser of the MPFS rate or the charge amount, providers will need to request a manual reopening/adjustment if their submitted charge is lower than the revised 2010 fee schedule amount. Medicare will allow this reopening beyond the usual one-year time limit. CMS also reminds providers that if the payment increases result in increased beneficiary cost-sharing amounts, it is acceptable to waive the increased beneficiary co-pay per the Office of Inspector General (OIG) policy related to waiving beneficiary cost-sharing amounts attributable to retroactive increases in payment rates resulting from the operation of new Federal statutes or regulations. For more information concerning the reprocessing of claims, go to: https://www.cahabagba.com/part_a/whats_new/20110208_jsm_11161.htm