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It is important to differentiate between ED professional and ED facility coding, and how levels of service are assigned. EDITOR’S NOTE: Recently, RACmonitor published articles referencing UnitedHealthcare/ Optum’s notice that they were changing the way they process emergency department (ED) claims, beginning April 1, 2020, along with how professional and facility…
Industry studies highlight large investments, yet ACOs struggle to integrate SdoH. Several major research studies have emphasized the large sums being spent by healthcare organizations to better manage the social determinants of health (SDoH), amid ongoing struggles to mitigate service gaps, especially by Accountable Care Organizations (ACOs). A study published…
Law professor Dershowitz tests the “one purpose test.” During the recent impeachment trial of President Trump, Alan Dershowitz made a statement that was widely interpreted as saying that if a politician had multiple motives for a particular activity, but one of the motives was benefiting the public interest, any nefarious…
Providers are deploying their own AI to fight back against the tyranny of algorithms. In October of last year (2019), President Trump signed the “Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors.” Section 9 of the Order entitled “Eliminating Waste, Fraud, and Abuse to Protect Beneficiaries and…
CMS says MOON errors will not affect billing/payment. EDITORS NOTE: This article is an update from last week's article Erroneous Guidance by NGS Could Pose Problems for Hospitals. Observation hours will not be removed from claims if hospitals fail to accurately complete and deliver to patients the Medicare Outpatient Observation…
ED physicians and healthcare providers are a distinct breed – whales in a sea of fish. After all, emergency room doctors have, for the most part, been overlooked by the Recovery Audit Contractor (RAC) auditors (or TPE, Targeted Probe-and-Educate; ZPICs, Zone Program Integrity Contractors; or Medicare Administrative Contractors, MACs). Maybe…
Are MACs going rogue? According to a webinar held last week, NGS, the Medicare Administrative Contractor (MAC), has taken the targeted probe-and-educate audits (TPE) to an area one would never expect: the proper completion and delivery of the Medicare Outpatient Observation Notice (MOON), the Centers for Medicare & Medicaid Services…
CMS report is based on 2016-2017 data. It’s been two years since the American Hospital Association (AHA) shouted from the rooftops that documentation by any interprofessional team would be accepted as validation to use the ICD-10-CM Z codes, as opposed to only documentation by physicians. In the social determinants of…