Tag Archives: medical necessity

Documenting medical necessity

CMS recently released a new National Coverage Determination (NCD), which was implemented on January 4. NCD 210.14 titled “Lung Cancer Screening with Low Dose Computed Tomography” is good news and expands the preventive services CMS offers its beneficiaries. Continue reading

Physicians and Coders: No More Unspecified Care

The team I work with has done an enormous amount of work translating medical necessity policies from ICD-9 to ICD-10. And we have had many discussions regarding the codes that represent “unspecified” care in ICD-10. Should they stay in the translations – or go? Is ICD-10 specific enough to cover all care and coding contingencies now?

Unspecified Defined

An internet search (don’t you love being able to search so easily?) revealed:

Un-spec-i-fied: (adjective) meaning “not stated clearly or exactly”. Synonyms: unnamed, unstated, unidentified, undesignated, undefined, unfixed, undecided, undetermined, uncertain… Continue reading

Observation Services: Documenting Medical Necessity (Part Two)

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

Observation Services: Documenting Medical Necessity (Part One)

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

Tinted Moisturizer and Medical Necessity Data

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

Medical Necessity Documentation – the Critical Component for CAC

Whether or not you can quote chapter and verse of the Medicare statute that first detailed medical necessity, most of us in healthcare are familiar with its premise1. But from this basic tenant we begin to diverge widely in our understanding of the concept. This is especially true for Medicare inpatient services since CMS does not have specific standards the industry can follow. This issue dates back to the late 1980s when then HCFA admitted, “Current regulations are general and we have not defined the terms ‘reasonable’ and ‘necessary’ nor have we described in regulations a process for how these terms must be applied…”2 Continue reading

CMS, 2-Midnights, and linking payment with what you want to achieve

A recurring theme in our blog posts is the need for payment policy to reflect a clearly defined purpose. Start with what you want to achieve and work backwards to a policy that delivers it. The ongoing saga of the CMS 2-Midnight rule is an excellent case study for this principle.

First, some history: CMS was/is faced with two related but distinct challenges. The first is the inexorable rise in observation stays, particularly those stays which exceed 48 hours. CMS observed an increase in the average duration of observation cases exceeding 48 hours from three percent in 2006 to eight percent in 2011. A subsequent OIG study put the rate at 11 percent in 2012. Extended observation creates a knock-on effect for beneficiaries, both for personal liability and qualification for post-acute care benefits. Hospitals blamed the increase upon aggressive Recovery Audit Contractors and rules that only paid for ancillary tests for inpatient admissions deemed unnecessary after review. This is not a determination that the service was not medically necessary, but rather that it need not have required an inpatient stay. Continue reading

Providers Dodge a Bullet: Reimbursement Might Have Been Tied to Hospital Medical Necessity Denials

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

Improve Medical Necessity Compliance in 2014

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

Medical Necessity: 2013 Year-in-Review

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