Becker's Healthcare September 25, 2024
Alan Condon

CMS has issued a final rule that is part of a broader effort to address suspicious billing activity in Accountable Care Organizations’ financial reconciliation.

Eight things to know:

1. A proposal in the 2025 physician fee schedule rule aims to address this issue for 2024 and beyond.

2. Two intermittent urinary catheter codes are flagged as highly suspect, and payments for them are excluded. Codes are considered suspect when there is an unexplained spike in claims, either in volume or dollar amounts, at the regional or national level.

3. The two codes identified as suspect are:

  • A4352 (Intermittent urinary catheter; Coude tip)
  • A4353 (Intermittent urinary catheter with insertion supplies)

4. CMS uses claims data from...

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Topics: ACO (Accountable Care), CMS, Govt Agencies, Payment Models, Provider, Value Based
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