American College of Physicians: Internal Medicine — Doctors for Adults ®

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HCFA to Medicare carriers: no more "black box edits"

From the November 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

HCFA has instructed Medicare carriers to stop performing "black box edits" on codes submitted by physicians.

As part of its Correct Coding Initiative, Medicare had told its carriers to use proprietary software to check physician coding for certain combinations of codes that it has deemed inappropriate. Physicians are denied payment for part or all of services that inappropriately use these code combinations.

Typically, Medicare carriers warn physicians about the coding combinations they consider inappropriate and will flag. With black box edits, however, physicians never knew exactly which code combinations carriers would deny. HCFA argued that because the software it was using is proprietary, it could not disclose the coding combinations it was searching for without violating the copyright of the software vendor.

Starting Sept. 5, Medicare carriers were instructed to stop using the commercial software to look for inappropriate code combinations.

Medical organizations like the College fiercely opposed the use of this type of methodology and referred to it as "black box editing." The College complained that physicians must be told which code combinations are unacceptable so they can change their coding patterns and avoid being penalized. For years, ACP­ASIM worked to convince HCFA and Congress that "black box edits" were unfair and inappropriate.

More information about the College's position is on the Web at www.acponline.org/hpp/hbstmt.htm#proprietary.

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