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…

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…

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.…

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…

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…

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…

Bad advice tends to circulate regarding how to select the correct E&M codes.   At a recent oncology conference in California, the speaker before me erroneously declared that the level of medical decision-making always controls the selection of code for any evaluation and management (E&M) service. She confidently asserted that…

Determining when and how to discharge adult patients can present some difficult dilemmas.  When I was a medical student (not that long ago,) my instructors emphasized a clear message over and over: decisions about patient care should never be tainted with consideration of cost. When I entered residency, however, things…

There are lessons to be learned from challenging the credibility of experts in medical necessity issues. Challenging the qualifications of an individual performing a medical necessity review can pay off. The dismissal of the HCR ManorCare case drew attention because the government’s expert lied and failed to disclose notes, but…

CMS has posted three new issues the RACs have proposed for auditing, pending CMS evaluation and approval. Last week the Centers for Medicare & Medicaid Services (CMS) created a new page on its Recovery Audit Contractor (RAC) website titled Provider Resources. CMS indicated that it will post on this page…