AHA Coding Clinic® for HCPCS - 2013 Quarter 2; For Your Information
Medicare coverage determinations
CMS has published a reminder to the hospitals under OPPS regarding Medicare coverage determinations. The information published in Transmittal 2664 on March 1, 2013, states: The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure or service may be paid if covered by the program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) determine whether a drug, device, procedure or other service meets all program requirements for coverage. For example, FIs/MACs determine that it is...
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Article Overview
This article explains a CMS reminder directed to hospitals under OPPS about Medicare coverage determinations. It summarizes the relationship between HCPCS assignment, OPPS payment, and separate coverage review by Medicare contractors, and it is relevant to hospital billing, reimbursement, and compliance teams. The article focuses on the general framework for determining whether a service is covered under Medicare and who makes that determination.
Why This Topic Matters
Understanding the distinction between payment methodology and coverage determination helps hospitals and coding staff avoid assuming that a payment rate means a service is covered. The article is useful for teams involved in Medicare billing, documentation review, and OPPS compliance.
What You Will Learn
- How Medicare coverage determinations are framed under OPPS
- The difference between payment assignment and coverage status
- The role of Medicare contractors in evaluating program requirements
- Why a payment rate does not by itself establish Medicare coverage
Who Should Read This
- Hospital billing staff
- Medical coders
- Compliance professionals
- Revenue cycle teams
- Medicare claims administrators
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