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CMS Shelves PTP, MUE Edits; Hospitals Are at Risk of Post-Pandemic Audits, Recoupment

CMS suspended many National Correct Coding Initiative (NCCI) edits in April, according to a memo from one vendor that scrubs claims for hospital billing systems. That means Medicare potentially is paying a lot of flawed claims, compliance officers said. Hospitals and other providers presumably will be hit with audits and overpayment demands when the edits are reinstated because it’s almost impossible to submit clean claims without the NCCI edits unless their vendors apply them independently of CMS.

“This creates huge potential postpayment audit risk and potential revenue loss,” said Steve Gillis, director of compliance coding, billing and audit at Partners HealthCare in Boston.

Because of the telehealth services expansion during the COVID-19 public health emergency, CMS said it’s temporarily suspending 74,144 facility procedure-to-procedure (PTP) edits and 291,902 professional PTP edits, as well as 197 facility medically unlikely edits (MUEs) and 196 professional MUEs, the memo said. The suspension of the edits is retroactive to Jan. 1.

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