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The decision to admit to inpatient or to place in observation is a medical necessity matter. On the American Case Management Association (ACMA) Learning Link, a member recently posed this question: “Does your institution use outpatient in a bed status or observation for surgical cases that do not meet inpatient…
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It is crucial to understand the differentiation between a denial for lack of medical necessity and a denial for incorrect status. Last week marked the eighth anniversary of the Centers for Medicare & Medicaid Services (CMS) release of ruling CMS-1455-R. This rule allowed inpatient admissions that were previously denied by…
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The Medicare IPO list was doomed years ago. For readers of and listeners to RACmonitor and Monitor Mondays, overthinking things is what we do. It’s the only explanation for our hand-wringing over the death of the Medicare inpatient-only (IPO) list.  To be clear, ending the IPO list is completely about…
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Sometimes, in an audit, it comes down to the definition of “medical necessity.” While the coronavirus pandemic is horrible already, it seems to be getting worse. But COVID has forced slight, positive changes in the telehealth arena – and, perhaps, in the widening of the ambiguous definition of “medical necessity”…
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Opdivo is an immunotherapy treatment for advanced cancer. What is Opdivo? It’s a new target for Recovery Audit Contractors (RACs), specifically Performant Recovery. Opdivo is an immunotherapy treatment for advanced cancer or cancers that have been resistant to other treatments. While this is a newer drug, Medicare will still cover…
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Some providers are experiencing high-volume denials based on idiosyncratic edits, made-up rules, and black-box edits. I have lost count of the number of publications released this year addressing surprise billing, incorrect use of Modifier 59, over-documentation, note bloat, billing for unnecessary services, over-prescribing of opioids, and myriad other topics targeting…
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Documentation is essential in order to avoid RAC problems. On the Sept. 9 edition of Monitor Mondays, Dr. John K. Hall made an excellent presentation on the coming Recovery Audit Contractor (RAC) audits of skilled nursing facility (SNF) decision-to-admit proof of skilled need, and how hospital documentation is essential to…
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The ruling focused on key hospice admissions. A recent RACmonitor article focused on the AseraCare case, wherein the 11th Circuit Court of Appeals concluded that if reasonable physicians differ about the medical necessity of care, a claim can’t be false. There were two other elements of the case worth emphasizing.…
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Ensuring your documentation meets medical necessity standards In 2003, the Centers for Medicare & Medicaid Services (CMS) made a change within the Claims Processing Manual regarding the selection of the evaluation and management (E&M) level of service to be effective in 2004. This change made the need, reason, or extensiveness…
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There are steps providers should take for holding managed care plans accountable. Considerable effort is regularly devoted by healthcare providers to overcome coverage denials through the application of the governing rules, such as they can be leveraged. Following the rules is tough in a world where money talks, bringing us…
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