Medicare Program

2021 Evaluation & Management Changes

Significant changes were made to the office and outpatient Evaluation and Management services in 2021. Read more about the updates in 2021 Coding Updates and Changes: CPT®, HCPCS, and ICD-10 CM and on the Coding and Reimbursement page.

 

Coding Edits

The National Correct Coding Initiative (NCCI) edits are developed by CMS to establish a uniform coding review method among MACs (Medicare Administrative Contractors). NCCI edits help the agency promote correct coding, enforce Medicare payment policies, and control improper payments made by inappropriate coding. The Centers for Medicare and Medicaid Services publishes updates to the NCCI edits for Procedure to Procedure and Medically Unlikely Edits on a quarterly basis. The organization also publishes the NCCI policy manual on an annual basis.

MLN Booklet: “How to Use the Medicare National Correct Coding Initiative (NCCI) Tools

 

Medicare Contractors

Map of MACs by state

MAC Contact Information

Targeted Probe and Educate Program (TPE)

Medicare Parts A & B Appeals Process

 

RAC Program Information and Resources

The Recover Audit Contractors (RAC) initiative was developed by the Centers for Medicare and Medicaid Services (CMS) to fight fraud and abuse in the Medicare program.

Map of RAC Regions

RAC Contact Information

CMS-Approved RAC Audits

 

Skilled Nursing Facility (SNF) Consolidated Billing

SNF Consolidated Billing resource

Resource: CMS’ Overview of SNF billing

 

National Coverage Determinations, Local Coverage Determinations, and Coding/Reporting Information

  • National coverage determination (NCD): a general outline of coverage which is applicable regardless to which Medicare Administrative Contractor (MAC) is administering claims for a region.
  • Local coverage determination (LCD): specific to a MAC.
  • National Coverage Analysis (NCA): a document published in response to a review request.
  • Local Coverage Articles (LCA): can act as companion pieces to local coverage determinations or stand alone to communication information about an item/service.

 

Search for policies with CMS MCD Search tool:

CMS MCD search tool

Refer to Medicare Coverage Determination Resource for more information regarding coverage determinations and the development process.

 

CMS Medicare Manuals

CMS’ internet-only manuals provide detailed information on Medicare eligibility, provider participation, benefits, coverage, claims processing and more.

Medicare Benefit Policy Manual

Medicare Claims Processing Manual

Medicare National Coverage Determinations Manual

Medicare Program Integrity Manual