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Reopening Not Appropriate to Change Diagnosis on Paid Claims

National Government Services periodically receives reopening requests to change the diagnosis on a paid claim. 

Submitting a new, or corrected diagnosis on a claim that has been submitted and paid does not qualify as a reopening, therefore, this is not an appropriate reopening request. 

When you need to add/correct a diagnosis on a paid claim, make a notation in the medical record of the correction/addition to ensure it is part of the record. The claim will not be corrected, therefore, a new remittance advice will not be issued. 

Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 34, Section 10 indicates “a reopening is a remedial action taken to change a binding determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record.”

Posted 3/22/2022