CMS Notice on Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services

August 2019 ~

CMS has posted a notice for physicians, hospitals, and other providers billing Medicare

Administrative Contractors (MACs) to ensure the payment window edits are bypassed when processing claims for donor post-kidney transplant complications services.

Change Request (CR) CR11312 directs MACs to implement logic that ensures they bypass payment window edits (3- days and 1-day) when processing claims for donor post-kidney transplant complications services. MACs will hold certain claims until Medicare’s Common Working File (CWF) system edits these claims correctly.

MACs must hold any donor post-kidney transplant complication services claims that receive the following edits until the CWF system implements CR11312:

3-Day Payment Window Edits:

• 7109: Outpatient Diagnostic Service against Inpatient in history
• 7113: Inpatient against Outpatient Diagnostic Service in history
• 7114: Outpatient Therapeutic Service against Inpatient in history
• 7115: Inpatient against Outpatient Therapeutic Service

1-Day Payment Window Edits:

• 7119: Outpatient Diagnostic Services against Inpatient in history
• 7120: Inpatient against Outpatient Diagnostic Services in history
• 7121: Outpatient Therapeutic Services against Inpatient in history
• 7122: Inpatient against Outpatient Therapeutic Services in history

NOTE: CR11312 makes no policy changes.

For more information, refer to MM7523 and CR11312.

Source(s): MLN Connects for August 15, 2019; MLN Matters Number MM11312;