By Marvin D Mitchell, RN, BSN, MBA
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…
By Ronald Hirsch, MD
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…
February 25, 2021
By Marvin D Mitchell, RN, BSN, MBA
Death of the Inpatient-Only List is NOT the Death of Medical Necessity
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…
November 5, 2020
By Knicole C. Emanuel Esq.
The Definition of Medical Necessity in the Era of COVID
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”…
October 8, 2020
By Knicole C. Emanuel Esq.
Warning: Opdivo is New RAC Target
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…
March 12, 2020
By Holly Louie, RN, BSN, CHBME
More Major Insurance Plans Using Proprietary Tactics to Deny Medically Necessary, Correctly Coded Services
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…
October 17, 2019
By Marvin D Mitchell, RN, BSN, MBA
Decision-to-Admit to a SNF Remains a Documentation Challenge
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…
September 26, 2019
By David M. Glaser, Esq.
Court decision upholds provider sovereignty over determinations of medical necessity: Part II
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.…
June 13, 2019
By Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®
My Patient is Bad – Very Bad
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…
May 16, 2019
By Marvin D Mitchell, RN, BSN, MBA
MA Plan Denials. Now What?
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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Adam J. KleinAllen Jost, PhDAlvin Gore, MD, CHCQM and Cathi Charlberg, LVN, CHCQMAmanda Gilliland, RN, BSNAmber Soucy, MSN, RNAndrew B. Wachler, Esq.Andrew B. Wachler, Esq. and Emma E. TrivaxAndrew H. Hughes, MD and Charles Locke, MD, CHCQM-PHYADVAndrew Wachler, Esq. and Kaitlin Nucci, Esq.Andrew Wachler, Esq., and Sarah Hillegonds, Esq.Angela Phillips, PTAspen AlbrightBarbara Vandegrift, RN, BSN, MABecky Rodrian, CPC, CEMC, CBCS, MBSBenjamin Kartchner MD, CHCQM-PhyAdvBrian T. LandryChristina Panos, RHIA, CTRChristopher Halleman, DOChristopher J. Laney, Esq.Chuck BuckClark AnthonyColleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RNDaniel Zirkman, MDDavid A. McKenzie, CAEDavid Jury MD, MSDavid M. Glaser, Esq.Delilah Davis, RN, BSN, CCADenise Coleman, LPNDenise Nash, MD, CCS, CIMDheeraj Mahajan, MD, FACPDuane Abbey, PhD, CFPEdward Hu, MD and Charles Locke, MDEdward Roche, PhD, JDElizabeth C. Dunbar, MD, MBA, FACEP, CHCQM-PHYADVEllen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPEllen Parucka Walker LCSW ACSWErica E. Remer, MD, CCDSErin Diesel Roumayah, Esq.Frank D. Cohen, MPA, MBBGlenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAMGloryanne Bryant, RHIA, RHIT, CCS, CCDSGreg FordHolly Louie, RN, BSN, CHBMEJ. Paul Spencer, CPC, COCJanelle Ali-Dinar, PhDJeffrey D. Lehrman DPM, FASPS, MAPWCAJessica Forster, Esq.John Foggle, MDJohn K. Hall, MD, JD, MBA, FCLM, FRCPCJulia K. Brodt, PhDJuliet B. Ugarte Hopkins, MD, CHCQM-PHYADVKaitlin Nucci Esq.Kathleen K. Borchard, BSN, RN-ACMKathy Seward, MD, CHCQM-PHYADVKim T. Charland, BA, RHIT, CCSKnicole C. Emanuel Esq.Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainerLaurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS TrainerLeslie Marsh, RN, BS, MSN, MBALori O’Hara, MA, CCC-SLPMadison AllenMaggie Elehwany, JDMark SpiveyMarvin D Mitchell, RN, BSN, MBAMary Beth Pace, RN, BSN, MBA, ACM, CMACMary Inman, Esq. and Anne Hayes Hartman, Esq.Mary Inman, Esq. and Max Voldman, Esq.Matt Lambert, MDMatthew AlbrightMaureen Testoni Esq,Max Voldman, Esq.Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDSMichael A. Salvatore, MD, FACPMichael KennedyMichael Rosen, Esq.Nancy J. Beckley, MB, MBA, CHCNena Scott, MSEd, RHIA, CCS, CCS-P, CCDSPhillip Angello, MDRalph Wuebker, MD, MBARichard “Dick” Beckley, YNS, USN, 1966-1970Robin Sewell, CDIP, CCS, CPC, CICRonald Hirsch, MDSarah Hillegonds, Esq.Sean M. Weiss, CEMA, CMCO, CPMA, CPC-P, CMPE, CMPM, CPC-PSean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC and David Glaser, Esq.Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®Stanley Nachimson, MSStefani Daniels, MSN, RN, CMAC, ACM and Tiffany Ferguson, LMSW, ACMStefani Daniels, MSNA, ACM, CMAC
