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…
UnitedHealth says it will use proprietary software to deny claims. EDITOR’S NOTE: The topic of this article was previously covered by RACmonitor on separate occasions in 2017 and 2018. To welcome the new year, UnitedHealthcare (UHC) has announced that starting April 1, 2020, they will use a proprietary software program…
Coding Guidelines and Conventions trump Coding Clinic. Hats off to coders.  This group of medical information professionals is required to master one of the most convoluted and confusing set of rules known to civilized man in order to categorize hospital services and submit their findings to insurance companies for billing.…
Issues abound in prominent payer coding guidance. By now, many hospitals have received denials for emergency department level-of-care coding. We could legitimately ask, “how did this happen?” Today we shall address how it started, why it’s important, and potential institutional responses. Denials for emergency care are not new. The spectrum…
Emergency departments (EDs) have been a hot-button topic in the battles over “surprise” billing.  Certainly, many patients use EDs inappropriately. We’ve all read and heard about uninsured patients, patients with no primary care provider, patients who simply abuse the fact that EDs are always open, patients with complaints that are…
Homelessness continues to be a compliance issue. Homelessness is a population health crisis. Doing nothing is not an option. Hospitals following existing law and best practices in population health management, within the confines of limits on resources, can make a difference. To truly address homelessness will require political will, as…
The most recent case involved a Zone Program Integrity Contractor (ZPIC), which turned a $4,000 overpayment into a $3 million overpayment using extrapolation. EDITOR’S NOTE: This is the second in a series of reports on alleged bias the author has uncovered in extrapolation audits. I recently wrote an article opining…
Don’t confuse your payer policy with providers’ medical degrees My recent article regarding secondary diagnosis coding and my advice to “just follow the guidelines” seems to have touched a nerve. Because it’s never quite that simple, is it? There’s the textbook answer on how we should be coding, and then there’s…
There is no need to worry about coding for HCCs or risk adjustment, writes the author. Just follow the coding guidelines. Confusion abounds regarding the application of Section IV ICD-10-CM Coding Guidelines. And while hospital outpatient coders may be more programmed to code additional diagnoses, physician pro-fee coders may just…
More than three dozen advocacy groups appear to sway position of one of the nation’s leading carriers. In the June 2017 UnitedHealthcare (UHC) Bulletin, it was indicated that the carrier would no longer cover consultation services within the evaluation and management (E&M) service codes, effective Oct. 1, 2017. UHC noted…
Page 1 of 2