In last week’s blog, I discussed observation services and private payer requirements. Now let’s take a look at CMS requirements which are a bit different. Observation is expected to be used when the physician presumes the patient will need less than 48 hours of care and the time in the hospital does not cross two midnights. Specifically, CMS says “The physician’s ‘expectation …should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.’” The CMS clinical and time expectations are similar to BCBS of NC. Continue reading
I shudder to think about the compliance quicksand surrounding observation services. Regardless, I’m going to attempt to explain how to document medical necessity for observation services (OBS). Fortunately – or unfortunately – depending on how you look at it, documentation requirements for medical necessity for OBS is not the same for all payers. Continue reading
I know what you are thinking – the woman has finally lost her mind. Or, this is the most ridiculous post I have ever seen – and I’m not going to waste my time reading it. Wait! I promise it will make sense.
Everyone has a favorite something – right? It’s a common enough story; in addition to holiday shopping this past weekend, I spent over an hour searching for a new tinted moisturizer to no avail. If you are a woman, you know what it’s like to have a favorite fragrance or lip gloss or nail color. Then, for some unknown and misguided reason, the manufacturer changes the formulation and it loses the je ne sais quoi that made it so special. Well, this just happened to my favorite aforementioned tinted moisturizer with sun screen! I want it back at any price – it has irreplaceable value to me. It was lightweight and matched my skin tone. Not too shiny or oily and just the SPF I need. I’ve searched but I can’t find a replacement I like. I trusted the product; it provided the ROI I was seeking. Continue reading
In keeping with the theme of previous blog posts–the professional realm of E&M coding–I’d like to discuss medical necessity as it relates to the final level of care. CMS has stated that medical necessity is the over-arching criterion for payment of E&M services, which, in pure CMS fashion, gives us a goal, but not guidelines as to how to get there. We have no medical necessity policies for the differing E&M codes.
I think we all understand the intent of that statement, which I interpret as “don’t game the system”. But how do I, as a coder, teach a provider how to do that? And, how does the provider document a record to reflect the medical necessity clearly? So, let’s put a pin in that and talk about the calculation of the E&M codes, then circle back. Continue reading
Doctors, nurse practitioners, nursing homes, lab, ambulance, and home health providers dodged a major bullet.
While it’s still freezing cold on the East Coast, CMS released Transmittal 505, Change Request 8425 on a very hot topic – extending record requests for medical necessity audits of admissions. The subject of the CR “Removing Prohibition” means (according to CMS) “allow(ing) the contractors to make a decision or take action on claims that are not currently being under review.”
But on March 19, 2014 CMS rescinded the transmittal citing “the need to clarify CMS’s policy” regarding removing prohibition. They also said the policy will not be replaced at this time. Let this be a warning: CMS came very close to denying collateral provider claims for medically unnecessary admissions. This is something they are obviously serious about. Continue reading
Welcome to 2014; did you make any resolutions? I did and I hope to have the dedication to reach the goals I’ve set for myself this year. Speaking of goals, I wrote about changes to compliance efforts in my final post of 2013. In this post, I would like to share a few thoughts on how to reach improved compliance in 2014.
Sell compliance upstairs: I know – I know, but support is essential. Remind the C-Suite or practice owner that due to sophisticated data more is known about what the organization/practice does and does not do. Information increases visibility and the likelihood of notice. Gaining support from leadership is an essential ingredient in accessing resources needed for improved outcomes. Providing examples of real monetary losses suffered by other providers can help support the need for action.
Don’t rely on “we’ve always done it that way before so it must be good enough” thinking: Continue reading
Can you believe it? We are saying farewell to another year. And a busy one it’s been from the medical necessity coding and compliance perspective.
The Feds were engaged in 2013 – at least three cardiologists were sentenced to jail time for issues such as placing stents in patients who did not meet criteria even though the physicians believed they were necessary. I recall that in once case the physician misrepresented the diagnosis in the record in order to meet medical necessity criteria. Continue reading
I was asked recently if the medical necessity data files that 3M calls ‘medical necessity dictionaries’ are the same as products that have medical necessity checking capabilities. It’s really a great question and if you are not in the software or data creation business it certainly can be confusing.
The medical necessity dictionaries are data files that 3M creates to mirror the CMS National Coverage Determinations (NCD) policies. Data is also created to represent Local Coverage Determination (LCD) policies created by the MAC (Medicare Administrative Contractors) vendors. The data files are content used in vendor, payer and hospital software systems. Continue reading
I don’t like math; numbers are not my friends. And statistics? Let’s not even go there – but Office of Inspector General (OIG) is already barreling down that road leaving hospital administrators shaking their heads.
Consider: In October, OIG fined the University of Miami Hospital $3.7+ million for extrapolated (assumed) medically unnecessary short stay admissions. To determine the fine, OIG used data mining techniques coupled with ‘statistical sampling ‘methodology. They then extrapolated to determine a total likely error rate. It works something like this: If Hospital A has X number of errors identified on Y number of claims, then Z likely represents the total number of medical necessity errors in their entire universe of short stay claims for a given date range. Using statistics, OIG determined a number of claims they believe were likely to have contained errors. This technique – according to OIG – is not new: Continue reading
For years, it seemed the Feds focused primarily on hospitals when looking at medical necessity issues. Even if an admission was determined to be a medically inappropriate site of service, the hospital got dinged, and the admitting physician got a pass. Hospital compliance officers have bemoaned this for years, not because they wanted to see the physician sanctioned, but because they felt alone on the medical necessity iceberg. The docs didn’t seem to mind since it did not impact their bottom line. Boy, are things changing: I was reading recently in Report on Medicare Compliance of the third cardiologist to be sentenced to jail time for inserting a stent in a patient whose blockage was less than the required 70 percent to support performance of the procedure. Even though the physician believed the stent placement was appropriate in this individual, he was convicted of misrepresenting the diagnosis in the record in order to support medical necessity.
To make this scenario even worse, only one patient’s stent procedure was misrepresented in the medical record, but the hospital had to refund all cases of stents placed by this physician for the past two years. Medicaid paid $6.088.45 for the one case that was found to be inappropriate, but the hospital had to repay the Feds $256,800! Continue reading