Medicare auditors’ authority to upcode or downcode has an upside and downside

June 14, 2015

“With great power comes great responsibility”
~ Voltaire

I doubt that Voltaire had medical coding on his mind during the Age of Enlightenment. But in the Age of Coding, his maxim certainly rings true.

Starting on May 4th, Medicare auditors added a new dimension to their authority. With the implementation of Transmittal 585, auditors now have the autonomy to change the level of codes billed and still pay the claim; they are able to upcode or downcode claims when a payable service was rendered, yet they believe the provider has selected the wrong code.

This is in effect for MACs (Medicare administrative contractors), RACs (recovery auditors), ZPICs (zone program integrity contractors), SMRCs (supplemental medical review contractors) and CERTs (comprehensive error rate testing contractors).

This new level of power brings with it advantages and potential drawbacks. On the upside, providers can receive some payment for a service without the need to appeal. A decrease in denials and appeals is certainly advantageous.

A potential flaw is that MAC auditors could target providers who bill a high number of multiple services. If this were to occur, then legitimate claims could suffer; providers may be inclined to select lower units from the outset knowing the auditors will be keeping a close eye.

Another disadvantage is the cost to contest a one-level variance can exceed the amount to be gained. This would produce a lose-lose scenario, even when you are correct in contesting the changed claim.

This extension of power was given to find a means of paying claims that would otherwise be denied for a small or obvious mistake. The question remains, is that the only reason this power will be exercised? Claims will forever remain subjective in nature, but hopefully the increased latitude given to Medicare auditors will only be used to make changes that, upon further inspection, are blatantly necessary and in the best interest of all parties involved.

Auditors, are you ready for the responsibility that comes with power?

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