Remark code M87 indicates that the claim or service(s) in question have been subjected to a Comprehensive Error Rate Testing (CERT) Contractor Audit and Payment (CFO-CAP) prepayment review. This means that before payment is issued, the claim is being reviewed to ensure compliance with Medicare policies and to prevent improper payments.
Common causes of code M87 are typically related to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) program, where claims are randomly selected for prepayment review to ensure compliance with Medicare coverage, coding, and billing rules. These causes may include:
1. Inconsistencies between the services billed and the documentation provided.
2. Missing or incomplete documentation to support the medical necessity of the services billed.
3. Errors in the coding of procedures, such as using outdated or incorrect codes.
4. Lack of adherence to specific billing guidelines or policies set forth by Medicare.
5. Suspicion of fraudulent or aberrant billing patterns that trigger a prepayment audit.
It's important for healthcare providers to meticulously review claims and supporting documentation before submission to avoid delays and denials associated with prepayment reviews like those indicated by code M87.
Ways to mitigate code M87 include implementing a robust pre-claim review process to ensure that all claims meet the necessary criteria before submission. This process should involve a thorough check of documentation to confirm that services rendered are medically necessary and are accurately reflected in the claim.
Additionally, staying updated on the latest CFO-CAP guidelines and training staff on these requirements can help prevent claims from being flagged for prepayment review.
Regular audits of claim submissions can also identify patterns that may trigger code M87, allowing for corrective action to be taken proactively.
It's also beneficial to establish a clear line of communication with the payer to understand any issues that led to the prepayment review and to address them promptly.
The steps to address code M87 involve first preparing and organizing all relevant documentation that supports the medical necessity and appropriateness of the services billed. This includes detailed clinical notes, test results, and any other pertinent medical records. Next, ensure that the claim is accurate and complete, with correct procedure codes, diagnosis codes, and any necessary modifiers.
If additional information is requested, respond promptly with the required documentation. It's also important to review the claim for any potential errors or omissions that could have triggered the prepayment review. If errors are found, correct them and resubmit the claim.
In the meantime, maintain open lines of communication with the CFO-CAP program to understand the status of the review and to respond to any additional requests. Keep track of all correspondence and documentation submitted in case of future disputes or appeals.
If the claim is denied after the prepayment review, evaluate the explanation provided and determine if an appeal is warranted. If so, follow the appeals process, providing a detailed rationale and supporting evidence for why the claim should be paid.
Throughout this process, it's crucial to monitor the impact on cash flow and to keep the affected healthcare providers informed about the status of the claim and any potential financial implications.